Category: Therapeutic Issue

Healing Trauma Through the Body: The Way In is the Way Out

Posted on by rezendevknowfully.com

Suzanne: A Case Study

Suzanne* arrives in my office due to a long history of anxiety, mild depression, problems sleeping, and relationship issues. She is 43, successful in her marketing career, and divorced, with a child in high school. She is a tall woman, but something about the way she carries herself makes her seem smaller than she is. She is wearing loose, dark clothing that doesn’t reveal much of her body. As she walks into my office for our first session, I am struck by the animation in her upper body, but I notice that she moves awkwardly because of the tightness in her shoulders, neck and upper spine. As I invite her to sit down, I notice that her eyes shift back and forth as if she’s looking for something. She seems uncomfortable meeting my gaze and looks quickly down at the floor each time our eyes meet. I can see by the way her shirt lies that her solar plexus area is very tight. It is clear that this tightness prevents her from taking a full, deep breath. She seems to be fighting upward against gravity, as if attempting to levitate. At the same time, I see and sense very little connection to her lower body. Her legs are almost completely still; they appear lifeless and detached. This gives her a weak and tenuous connection to the earth. “It’s as if everything from above the waist is surging wildly upward, like a thousand bees swarming skyward, out of a hive, centered above her navel.”
 
She complains of rapid heart rate, shallow breathing, food sensitivities, digestion problems, and difficulty staying asleep. As she talks, I can hear her mouth is dry. It makes sense to me that she is experiencing anxiety—my understanding of how the nervous system works lets me know that her system is stuck in a constant state of fear and readiness. As a Somatic Experiencing® (SE) practitioner, I can tell that Suzanne is in a common feedback loop that occurs in people who are attempting to manage their internal nervous system dysregulation. Shallow breathing and tightness in her chest keep her body in a constant state of oxygen deprivation. This escalates the anxiety, so she tightens the muscles in her chest even more. I take a mental note—I’ll need to address this pattern.
 
Suzanne begins to tell me about a recent conflict she experienced at work with a male co-worker. As she describes the situation, she cries easily but not comfortably, trying to hold back the tears. When she does begin to cry, she holds her breath and squints her eyes tightly, as if trying to squeeze the tears back into her eyes. She swallows repeatedly and her shoulders tighten even more. She’s working hard to keep the emotions in check. At one point in her description, she chastises herself for being so reactive. “I should be able to handle these types of situations,” she says. “Instead, when there’s conflict, I get totally emotional. Even though my mind is racing with thoughts, I can’t do or say anything. I feel paralyzed. I don’t act like a competent professional. I just sit there and cry like a little girl.”
 
She looks down, rounds her shoulders, and holds her breath. I listen to her words and make a note of how she describes her experience, but I am especially paying attention to what her body is telling me. “As I listen to her, I’m receiving a lot of information about her by paying attention to my own bodily experience.” I feel a little breathless and pulled upward in my own body—I need to keep reminding myself to breathe, soften my belly, and feel my feet and pelvis.
 

Approach

It is obvious from the above description that my attention is heavily focused on the physical presentation of the client.  Of course, I am not ignoring the content of her narrative, but I am especially attuned to the story her body is telling. My approach is guided by the principles of Somatic Experiencing, developed by Peter Levine from his research into the stress responses of animals in the wild. Physiological responses to stressful situations arise from what is classically called the sympathetic or “fight-or-flight response.” Levine noticed that once an animal was out of danger, its body automatically shifted to “parasympathetic” rest and recovery with gentle trembling, shaking, deep breaths, sweating, and sometimes more aggressive fight-reenacting behaviors—a process called discharge. These behaviors reset the nervous system to a pre-threat level of functioning. This discharge cycle appeared to be essential to recovery: experts repeatedly told Levine that if animals were unable to complete the discharge process, they would die.
 
Given that humans should be equipped with the same restorative capacities, Levine pondered, what makes us different? What gets in the way of our recovery? 
 
Through hundreds of hours of client sessions, Levine began to witness how clients’ bodies told their stories of trauma, even if the clients had no specific memories. Once Levine guided them into the sensate experience of trauma, the body then took over and finished what was unprocessed, or incomplete, much like the animals he’d observed. Clients receive the added gifts of increased body awareness, a stronger connection to self, a shift in deep-seated patterns, a more regulated nervous system, and a sense of mastery.
 
Why do humans need to be guided at all? The biggest obstacle is how inattentive and unfamiliar we are with our physical sensations. Our big, sophisticated brains constantly out-think and override our bodily needs. We are trained to ignore signs of hunger, pain, discomfort, injury, danger, as well as pleasure, saturation, and fulfillment. What’s astonishing is how forgiving and responsive the body is. As soon as we tune into it, shifts begin to happen.
 

Getting Unstuck

Within my framework as an SE practitioner, Suzanne’s symptoms imply something in her system is stuck, unfinished. I can assume that during some traumatic experience in her past, she froze or was overpowered by someone or something bigger, stronger, or faster. 
 
Suzanne’s array of emotional and physical complaints is typical of autonomic dysregulation. Dysregulation shows up in basically two extremes: stuck “on” and stuck “off.” The former can manifest as anxiety, panic, mania, hypervigilance, sleeplessness, dissociation, attention deficit, OCD, emotional flooding, chronic pain, hostility/rage, etc. This is the sympathetic branch of the nervous system, responsible for moving us out of danger. When traumatic material is unprocessed, the residual activation keeps a person locked in a constant state of readiness and reactivity. The client has an ongoing sense that “something bad can happen at any moment.”
 
Being stuck off shows up as depression, flat affect, lethargy, exhaustion, low impulse/motivation, chronic fatigue, dissociation, many of the complex syndromes, low blood pressure. This is the parasympathetic branch of the autonomic nervous system. In a healthy state of functioning, it is designed to bring the body back to rest and recovery after surges of sympathetic activity. When it goes awry, the system slows or shuts down too much, or “depresses” itself at the slightest trigger.
 
Clients may present with one extreme or oscillate between the two. At first glance, Suzanne presents more on the sympathetic scale, excepting her legs. I’ll want to guide her inward so we can begin to sense more deeply into her pattern.The goal of SE is to work through traumatizing events in non-traumatizing ways. If I can ease her through whatever defenses or strategies her body has taken on to manage the dysregulation, her body will take over and complete the necessary response that was not able to occur when she was initially traumatized. It will be part of my treatment plan with her to assist her body in feeling all possible impulses. She may want to cower self-protectively, defend herself, or run from the danger.
 
“SE therapists have to learn to watch, not just listen; to know when to slow down, when to point out and explore a physical response.” We must learn how to ask open-ended questions that invite curiosity about one’s experience in the moment. Our job is to support the client in accessing what is happening inside at the physiological level, and then to assist in the return to self-regulation. We are restoring the client’s system back to an organic level of functioning. The client grows in self-mastery, and the therapist is merely the guide.
 
SE uses a variety of techniques that are presented at a pace that helps the client to stay with every moment of the event without flooding, compensating or dissociating. Slowing everything down and keeping Suzanne focused on her bodily sensations will help us do this. It’s a bit like watching the event on a video, pausing at every single frame, and allowing each detail, emotion, sensation, bodily reaction, impulse, and defensive reaction to be felt and processed. Connecting to the physiological responses also prevents her mind from coming in and doubting or worrying.
 
In this sense, we can see that, for a traumatized person, going into the body and coming into contact with their physiological experience is the way out of their distressing symptoms. The way in is the way out. Many models of treatment focus on eliminating symptoms and behaviors, but SE takes the client into the symptoms knowing that the symptoms are the key to healing trauma. With Suzanne – as with all of my clients – I will begin my work with her wherever she is and with whatever her body is displaying in the moment. By focusing on one aspect of her physical sensations, we will be led into her body’s memory of the trauma. By moving slowly, and utilizing various techniques that prevent re-traumatization, her body will guide her through her own natural set of experiences, and gradually release the stuck pattern.
 

The Work: Careful Amplification, Attentiveness

To begin my work with Suzanne, I will want to take her into a direct experience of the physical sensations in her body. I first want to be sure that Suzanne has the capacity to work somatically with the material she is presenting. I will be able to assess Suzanne’s overall nervous system stabilization when I see how her body reacts initially as we begin to explore bodily sensations. I will also be able to get clear information on how she attempts to manage the sensations by watching her response to them. As she begins to feel her body, does she brace, collapse, tighten all over, hold her breath, dissociate, shut down, get angry or become judgemental?
 
As she is finishing her description of the conflict with the co-worker, she begins to tell me again of her general anxiety, in part, she says, because she can’t trust herself to respond in situations where she needs to. I feel as if this is a good time in the session to begin to tune into her sensations, so I ask her permission to explore her experience a little.
 
She agrees, a bit hesitantly, and I ask her to notice where in her body at this moment she is sensing the anxiety. She looks down and then says, “In my belly.” As she focuses her awareness on the sensations in her belly, she escalates quickly—her shoulders tighten, she holds her breath. She looks frightened. I remain calm and unalarmed because I have seen this many times. “Can you give me some words to describe the sensations?” I ask her. She puts her hand on her belly, and says, “It’s churning, hot, and it’s moving really quickly.”
 
At this point, “I know that I need to broaden her awareness and to help her know that she can touch into the intensity of her experience without becoming overwhelmed by it”, as well as to help her move her attention to areas of less intensity. To do this, I ask Suzanne if she can also notice the chair supporting her thighs, and the floor beneath her feet. My goal here is to build resilience and confidence, and dispel any belief Suzanne may have that she can’t handle this experience.
 
Secondly, by asking her to feel outside of an energetic hot zone, her body recognizes that there is more square footage for the intensity to inhabit. This naturally makes a little more space for the concentration of the sensations; they spread out. Thirdly, by contacting the periphery of her body, it helps Suzanne feel solid, reliable areas, which provide the sense of a container.
 
Suzanne closes her eyes and I see her body visibly settle into the chair. Her shoulders drop slightly, the muscles in her face soften and she is breathing more deeply. She seems to allow the chair to hold her a bit more, rather than holding herself up and off it. This is a very important moment and I want to grab it.
 
Suzanne looks up at me, surprised. I smile at her. “Tell me what you’re experiencing now.”
 
“Things are relaxing,” she says, her voice is softer and her words come out more slowly.
 
“What does relaxing feel like in your body?” I ask her. 

“My stomach has softened," she tells me. "I feel more air in my belly and I don’t feel as afraid.”
 
Another important moment. This is the first shift in Suzanne’s breathing pattern—a crucial element in the stuck anxiety pattern in her body. Remember, when breathing is rapid, tight and fast, it actually triggers the body’s fight-or-flight reaction. As the body goes into this reaction, the breathing becomes constricted, fast and shallow—a frustrating chicken-or-egg phenomenon. I want to expand on Suzanne’s feeling of being able to breathe. So I ask her to sense into her belly, noticing how it feels to have more air.
 

Relating to Anxiety

This experience lays the groundwork for Suzanne to be able to enter into intense sensations and then find a way to regulate them. I want her to really have a felt sense of this, so I decide to guide her into it a few times as practice. I ask her to consciously bring up something that triggers her feeling of anxiety, like her co-worker. As she thinks of him, the anxiety begins to rise again and I guide her into the sensations in her belly, then down to her feet. As we do this repeatedly, Suzanne discovers that if she moves into noticing her feet whenever the sensations of anxiety get too intense, she can stay longer and longer with the anxiety and the intensity subsides drastically.
 
I feel that we have done enough work in this area and I want to check in with Suzanne to see how she is handling this. Her face appears to be shining a bit; there is more blood flow and a pinker color to her cheeks and for the first time in the session. She smiles. I ask her about this. She looks a little sheepish, averting her gaze for a moment. Then she looks back at me and says, “This is cool. I feel so much more in charge.”
 
I want to anchor her bodily sense of being “in charge” so that she can access this when her anxiety arises. “I am hoping to help change her relationship to this anxiety—to become curious about it.” I want her to recognize that when she actually pays attention to it, at the sensation rather than emotional level, it usually subsides, rather than increases as most people fear.
 
This process of touching into her sensations of the anxiety, then shifting her awareness to the rest of her body, helping her notice any moments of settling or any shift that occurs naturally, is one of the many ways that SE supports the nervous system to re-establish its natural, inherent rhythm—one that flows seamlessly between excitation and relaxation, between contraction and expansion. This is the first step Suzanne and I have taken to restoring regulation in her system.
 

Unfinished Business

The second step we’ll need to take is to access what’s unfinished. Many traditional therapies focus on feeling, reliving, and ultimately putting behind many of the bad things that occur in childhood. While this can be an important part of the therapeutic process, and is definitely something I am concerned with, my SE orientation leads me to seek to explore this experience with Suzanne somatically. “By following the body’s wisdom, we are led to what didn’t get to happen in a client’s past.” We provide clients with the opportunity of re-doing the event—finding in the present the way that the body would naturally, organically respond if it was left to its own devices. This renegotiation is done almost entirely through visualization, and slow, intentional movements, deeply connected to sensations and procedural movement patterns. This allows the discharge process to complete, and the trauma symptoms are moved out of the body, while the nervous system is allowed to return to pre-trauma functioning.
 
To get to what is unfinished in Suzanne, I want to access the brainstem and the survival responses. The way in is via sensations, noticing physiological shifts, and sensing impulses. My work with Suzanne so far has tapped into a little (but not too much) of the activation, or the charge of the anxiety. Now it’s time to check in to the rest of her body—in particular her extremities. The extremities naturally spring into readiness and action when we feel threatened. When a person is unable to carry through with the impulse to flee or fight, these thwarted impulses interrupt hard-wired sensorimotor patterns. This is often the place where the system gets stuck.
 
Capitalizing on Suzanne’s feeling of excitement and mastery, I ask her if she’s willing to explore a bit further. This time, when she gives her assent, she doesn’t hesitate. I ask her to sense into the rest of her body to notice what else is going on.
 
She immediately reports, “I feel tightness in my legs and shoulders.”
 
Deciding to bring awareness to the less accessible lower body, I ask her to tell me where she feels the tightness in her legs. She reports feeling tension and tingling in her ankles and thighs. Suzanne’s lifeless legs indicate a parasympathetic orientation in her lower body—a common pattern in clients with a history of physical or sexual abuse, bullying, early surgical procedures, or any events that involve being restrained. Earlier she had described herself as “feeling paralyzed” and “crying like a little girl” in response to the conflict and perceived threat of her co-worker. It’s clear to me that at least some of this sense of paralysis originates in her legs. I encourage her to stay with the sensations and see what happens next as she does that.
 
“It’s getting tighter,” she says.
 
Wanting to gently encourage her, I murmur, “Stay with it, if that’s okay.” I see her legs jump and tense slightly and then become very still.
 
“I’m scared,” Suzanne says. “I want to move my legs, but I can’t.”
 
This is a very important moment in SE work—an experience that Levine describes as the brake and accelerator both floored at the same time—the core of the freeze response. It is high-level sympathetic mobilization, coupled with parasympathetic shutdown, similar to what happens when a circuit breaker blows when there’s too much charge going through a line. It will be necessary to separate the two impulses so that Suzanne’s defensive response can be completed.
 

Follow the Impulse

Before I can say anything else, Suzanne says again, “I’m scared. I know this feeling. This is like when my uncle would do things to me in the attic.”
 
While I am certain that we will need to explore the content that is beginning to naturally arise as a result of feeling into Suzanne’s sensations, at this point I want to stay grounded in her physiological experience. In my experience, if I chose to explore this reference to her uncle by asking her to tell me more about what happened in the attic, Suzanne would likely shift into an intellectual telling of the story. This would take us away from her body and what her body wants to do. In fact, her body has been telling this story from the beginning, now showing us the connection between her anxiety and paralysis in her conflict with her co-worker and her past experience of trauma.
 
I ask Suzanne if it’s okay to sense the energy in her legs.
 
She says yes, a little uncertainly. She pauses for a moment and then responds, “It feels very intense, like a strong humming feeling.” My initial impression of her “wild bee” energy seems accurate. I ask her to feel the energy and sense where it wants to go. I also ask if she can feel how she is holding it back. I encourage her to very slowly move her awareness back and forth between the wanting to move and the holding back. This technique helps to separate the conflicting impulses. 
 
Suzanne is alert and somewhat alarmed, but not overwhelmed, mostly because we have done good preliminary work earlier, where she learned to trust her body somewhat, and learned to trust her ability to handle intensity. As Suzanne tunes into the energy wanting to move, the holding begins to ease, and the impulse to move increases. I see her upper body relax slightly, while her legs begin to twitch. I point out the twitching in her legs and invite her to slowly feel that and follow what wants to happen. Her body wants to move in reaction to a threat (her uncle), but it can’t because the threat is larger, stronger and familiar. Several intense, involuntary impulses are happening at the same time: anxiety because of the danger, hormones racing through her system preparing for action, tightness and bracing in many parts of her body, feelings of helplessness, hopelessness and shame, to name a few.
 
I can see underneath Suzanne’s clothes that her thighs are contracting slightly; her feet jerk almost imperceptibly upward. I also feel the readiness in my own body, which I experience as tension in my legs; my heart rate increases. I am feeling a sense of excitement in my  body—these impulses are contagious, and many-less experienced practitioners initially make the mistake of getting swept up in the sensations, unintentionally pressuring the client and causing resistance. Not wanting her to feel pushed, I sit back, settle into the chair, and move my attention back slightly, to allow her to experience her own impulses uninfluenced by mine.
 
I ask her to feel into the tightness of her thighs, and to sense her calves and ankles. They very slowly begin to move on their own, and I encourage her to notice that.
 
““My legs feel powerful and strong, like they could leap over any mountain,” she says, her voice sounding stronger and more commanding than I’ve heard it yet in this session.”
 
“Stay with those sensations of strength and power,” I suggest to her. I can see that she is enjoying the strength she feels. She pushes her feet down into the floor, her thigh muscles contracting visibly. I see that her feet and legs continue to move very slightly, this time with larger movements. I stay alert for signs of dissociation, bracing, breath-holding—anything that would indicate that too much is happening too fast.
 
As Suzanne continues to experience the movement of her legs and feet, she says, “It feels great to move them.” Her legs pump slightly beneath her seat. “ I don’t think I’ve felt my legs for years. Its like I’m coming into them.”
 
I ask her to tell me a little bit more about what she is sensing. “Heat. Waves of heat coursing through my legs.” Her feet and ankles continue to move as she describes this. I know that the release of heat is a sign that her nervous system is coming into a greater degree of equilibrium. To continue to expand on Suzanne’s experience of becoming unfrozen, I ask her, ”What does it feel like your feet are doing?”
 
“I can walk away. I know I can walk away. I can run away if I need to.”
 
Her legs begin to tremble very slightly. Her face is flushed, radiating pleasure. I know we have done plenty for one session.
 
At this point, it's time to process some of what we’ve done. We talk about her experience and I educate her a bit on the SE model I’ve been using, explaining the fight-or-flight process of the nervous system and what happens when those natural reactions are unable to be completed. She shares some memory flashes that arose during the running, and we talk about ways she can play with the process of checking into her belly when she feels anxious—moving between the sensations in her belly and the sensations in her legs.
 

The Next Step

Future sessions with Suzanne would focus on fine-tuning the newfound skill of sensing the anxiety somatically,  and learning how to recognize it, and settle it before it overtakes her. We would look at other situations in which anxiety shows up, such as in the work place or during  moments of conflict, and see if we can generalize the skill in other settings. We would explore the abuse by her uncle, concentrating on what is unprocessed physiologically and emotionally, especially incomplete defensive responses. SE therapists learn to trust the body, more than the memory or recall of events. We know not to assign meaning or assume causality to what arises in the therapy session. Details of events change as they are worked out at the somatic level. Memory is unreliable at best, but the body holds the key to what is unfinished and needing to heal. We focus on allowing those physiological responses to unfold, which makes room for the body to organically return to homeostasis.
 
In the SE model, we consider our work to focus on resolving the strategies for coping with nervous system dysregulation. This dysregulation can occur as the result of trauma, but may occur even in the absence of specific traumatic events—early attachment issues, for example. What is primary to us is to restore the nervous system to a natural state of regulation. To this end, SE is well integrated with many modalities of therapy, adding richness and depth to other methods that may have a more primary focus on the emotional or cognitive aspects of experience. What is most important about the SE way of working with a client is our focus on the physiological, the sensations, the body.
 
A wealth of information can be found at the Foundation for Human Enrichment web site. A comprehensive SE Training program is available for those seeking to learn how to apply this method in their work. A vivid demonstration of SE is seen in Resolving Trauma in Psychotherapy: A Somatic Approach.

“When I’m good, I’m very good, but when I’m bad I’m better”: A New Mantra for Psychotherapists

Posted on by rezendevknowfully.com
Current estimates suggest that nearly 50 percent of therapy clients drop out and at least one third, and up to two thirds, do not benefit from our usual strategies. Barry Duncan and Scott Miller provide a comprehensive summary of the Outcome-Informed, Client-Directed approach and a detailed, practical overview of its application in clinical practice. Through case examples they demonstrate how most practitioners can increase their therapeutic effectiveness substantially through accurate identification of those clients who are not responding, and addressing the lack of change in a way that keeps clients engaged in treatment and forges new directions.

Introduction

At first blush, Mae West's famous words 'When I'm good, I'm very good, but when I'm bad I'm better' hardly seem like a guide for therapists to live by—but, as it turns out, they could be. Research demonstrates consistently that who the therapist is accounts for far more of the variance of change (6 to 9 percent) than the model or technique administered (1 percent). In fact, therapist effectiveness ranges from a paltry 20 percent to an impressive 70 percent. A small group of clinicians—sometimes called 'supershrinks'—obtain demonstrably superior outcomes in most of their cases, while others fall predictably on the less-exalted sections of the bell-shaped curve. However, most practitioners can join the ranks of supershrinks, or at least increase their therapeutic effectiveness substantially.
 
Consider Matt, a twenty-something software whiz who was on the road frequently to trouble-shoot customer problems. Matt loved his job but travelling was an ordeal—not because of flying but because of another, far more embarrassing problem. Matt was long past feeling frustrated about standing and standing in public restrooms trying to 'go.' What started as a mild discomfort and inconvenience easily solved by repeated restroom visits had progressed to full-blown anxiety attacks, an excruciating pressure, and an intense dread before each trip. Feeling hopeless and demoralized, Matt considered changing jobs but as a last resort decided instead to see a therapist.
 
Matt liked the therapist and it felt good finally to tell someone about the problem. The therapist worked with Matt to implement relaxation and self-talk strategies. Matt practiced in session and tried to use the ideas on his next trip, but still no 'go.' The problem continued to get worse. Now three sessions in, Matt was at significant risk for a negative outcome—either dropping out or continuing in therapy without benefit.
 
We have all encountered clients unmoved by treatment. Therapists often blame themselves. The overwhelming majority of psychotherapists, as cliched as it sounds, want to be helpful. Many of us answered "I want to help people" on graduate school applications as the reason we chose to be therapists. Often, some well-meaning person dissuaded us from that answer because it didn't sound sophisticated or appeared too 'co-dependent.' Such aspirations, we now believe, are not only noble but can provide just what is needed to improve clinical effectiveness. After all, there is not much financial incentive for doing better therapy—we don't do this work because we thought we would acquire the lifestyles of the rich and famous.
 
Unfortunately, the altruistic desire to be helpful sometimes leads us to believe that if we were just smart enough or trained correctly, clients would not remain inured to our best efforts—if we found the Holy Grail, that special model or technique, we could once and for all defeat the psychic dragons that terrorize clients. “Amid explanations and remedies aplenty, therapists search courageously for designer explanations and brand-name miracles, but continue to observe that clients drop out, or even worse, continue without benefit.” Current estimates suggest that nearly 50 percent of our clients drop out and at least one third, and up to two thirds, do not benefit from our usual strategies.
 
So what can we do to channel our healthy desire to be helpful? If we listen to the lessons of the top performers, the first thing we should do is step outside of our comfort zones and push the limits of our current performance—to identify accurately those clients not responding to our therapeutic business as usual, and address the lack of change in a way that keeps clients engaged in treatment and forges new directions.
 
To recapture those clients who slip through the cracks, we need to embrace what is known about change: Many studies reveal that the majority of clients experience change in the first six visits—clients reporting little or no change early on tend to show no improvement over the entire course of therapy, or wind up dropping out. Early change, in other words, predicts engagement in therapy and ongoing benefit. This doesn't mean that a client is 'cured' or the problem is totally resolved, but rather that the client has a subjective sense that things are getting better. And second, a mountain of studies have long demonstrated another robust predictor—that reliable, tried-and-true but taken-for-granted old friend—the therapeutic alliance. Clients who highly rate the relationship with their therapist tend to be those clients who stick around in therapy and benefit from it.
 
Next we need to measure those known predictors in a systematic way with reliable and valid instruments. So instead of regarding the first few therapy sessions as a 'warm-up' period or a chance to try out the latest technique, we engage the client in helping us judge whether therapy is providing benefit. Obtaining feedback on standardized measures about success or failure during those initial meetings provides invaluable information about the match between ourselves, our approach, and the client—enabling us to know when we are bad, so we can be even better. The only way we can improve our outcomes is to know, very early on, when the client is not benefiting—we need something akin to an early warning signal.
 
Using standardized measures to monitor outcome may make your skin crawl and bring to mind torture devices like the Rorschach or MMPI. But the forms for these measures are not used to pass judgment, diagnose or unravel the mysteries of the human psyche. Rather, these measures invite clients into the inner circle of mental health and substance abuse services—they involve clients collaboratively in monitoring progress toward their goals and the fit of the services they are receiving, and amplify their voices in any decisions about their care.

The Outcome Rating Scale (ORS)

You might also think that the last thing you need is to add more paperwork to your practice. But finding out who is and isn't responding to therapy need not be cumbersome. In fact, it only takes a minute. Dissatisfied with the complexity, length, and user- unfriendliness of existing outcome measures, we developed the Outcome Rating Scale (ORS) as a brief clinical alternative. The ORS (child measures also available) and all the measures discussed here are available for free download at talkingcure.com. The ORS assesses three dimensions:
  1. Personal or symptomatic distress (measuring individual well-being)
  2. Interpersonal well-being (measuring how well the client is getting along in intimate relationships)
  3. Social role (measuring satisfaction with work/school and relationships outside of the home)
Changes in these three areas are considered widely to be valid indicators of successful outcome. The ORS simply translates these three areas and an overall rating into a visual analog format of four 10-cm lines, with instructions to place a mark on each line with low estimates to the left and high to the right. The four 10-cm lines add to a total score of 40. The score is simply the summation of the marks made by the client to the nearest millimeter on each of the four lines, measured by a centimeter ruler or available template. A score of 25, the clinical cutoff, differentiates those who are experiencing enough distress to be in a helping relationship from those who are not. Because of its simplicity, ORS feedback is available immediately for use at the time the service is delivered. Rated at an eighth-grade reading level, the ORS is understood easily and clients have little difficulty connecting it their day-to-day lived experience.
 
Matt completed the ORS before each session. He entered therapy with a score of 18, about average for those attending outpatient settings, but continued to hover at that score. At the third session, when the ORS reflected no change, it was not front-page news to Matt. But a different process ensued. In the same spirit of collaboration as the assessment process, Matt and his therapist brainstormed ideas, a free-for-all of unedited speculations and suggestions of alternatives, from changing nothing about the therapy to taking medication to shifting treatment approaches. During this open exchange Matt intimated that he was beginning to feel angry about the whole thing—real angry. The therapist noticed that when Matt worked himself up to a good anger—about how his problem interfered with his work and added a huge hassle in any extended situation away from his own bathroom—that he became quite animated, a stark contrast to the passively resigned person that had characterized their previous sessions. One of them, which one remains a mystery, mentioned the words 'pissed off' and both broke into a raucous laughter. Subsequently, the therapist suggested that instead of responding with hopelessness when the problem occurred, that Matt work himself up to a good anger—about how this problem made his life miserable. Matt added (he was a rock-and-roll buff) that he could also sing the Tom Petty song "Won't Back Down" during his tirade at the toilet. Matt allowed himself, when standing in front of the urinal to become incensed—downright 'pissed off,' and amused. And he started to go.
 
This process, the delightful creative energy that emerges from the wonderful interpersonal event we call therapy, could have happened to any therapist working with Matt. The difference is that the use of the outcome measure spotlighted the lack of change and made it impossible to ignore. The ORS brought the risk of a negative outcome front and center and allowed the therapist to enact the second characteristic of supershrinks, to be exceptionally alert to the risk of dropout and treatment failure. In the past, we might have continued with the same treatment for several more sessions, unaware of its ineffectiveness or believing (hoping, even praying) that our usual strategies would eventually take hold, but the reliable outcome data pushed us to explore different treatment options by the end of the third visit.
 
Pushing the limits of one's performance requires monitoring the fit of your service with the client's expectations about the alliance. The ongoing assessment of the alliance enables therapists to identify and correct areas of weakness in the delivery of services before they exert a negative effect on outcome.
 

The Session Rating Scale (SRS)

Research shows repeatedly that clients' ratings of the alliance are far more predictive of improvement than the type of intervention or the therapist's ratings of the alliance. Recognizing these much-replicated findings, we developed the Session Rating Scale (SRS) as a brief clinical alternative to longer research-based alliance measures to encourage routine conversations with clients about the alliance. The SRS also contains four items. First, a relationship scale rates the meeting on a continuum from "I did not feel heard, understood, and respected" to "I felt heard, understood, and respected." Second is a goals and topics scale that rates the conversation on a continuum from "We did not work on or talk about what I wanted to work on or talk about" to "We worked on or talked about what I wanted to work on or talk about." Third is an approach or method scale (an indication of a match with the client's theory of change) requiring the client to rate the meeting on a continuum from "The approach is not a good fit for me" to "The approach is a good fit for me." Finally, the fourth scale looks at how the client perceives the encounter in total along the continuum: "There was something missing in the session today" to "Overall, today's session was right for me."
 
The SRS simply translates what is known about the alliance into four visual analog scales, with instructions to place a mark on a line with negative responses depicted on the left and positive responses indicated on the right. The SRS allows alliance feedback in real time so that problems may be addressed. Like the ORS, the instrument takes less than a minute to administer and score. The SRS is scored similarly to the ORS, by adding the total of the client's marks on the four 10-cm lines. The total score falls into three categories:
  • SRS score between 0–34 reflects a poor alliance,
  • SRS Score between 35–38 reflects a fair alliance,
  • SRS Score between 39–40 reflects a good alliance.

The SRS allows the implementation of the final lesson of the supershrinks—seek, obtain, and maintain more consumer engagement. Clients drop out of therapy for two reasons: one is that therapy is not helping (hence monitoring outcome) and the other is alliance problems—they are not engaged or turned on by the process. The most direct way to improve your effectiveness is simply to keep people engaged in therapy.

 
An alliance problem that occurs frequently emerges when client's goals do not fit our own sensibilities about what they need. This may be particularly true if clients carry certain diagnoses or problem scenarios. Consider 19-year-old Sarah, who lived in a group home and received social security disability for mental illness. Sarah was referred for counseling because others were concerned that she was socially withdrawn. Everyone was also worried about Sarah's health because she was overweight and spent much of her time watching TV and eating snack foods.
 
In therapy Sarah agreed that she was lonely, but expressed a desire to be a Miami Heat cheerleader. Perhaps understandably, that goal was not taken seriously. After all, Sarah had never been a cheerleader, was 'schizophrenic,' and was not exactly in the best of shape. So no one listened, or even knew why Sarah had such an interesting goal. And the work with Sarah floundered. She spoke rarely and gave minimal answers to questions. In short, Sarah was not engaged and was at risk for dropout or a negative outcome.
 
The therapist routinely gave Sarah the SRS and she had reported that everything was going swimmingly, although the goals scale was an 8.7 out of 10, instead of a 9 or above out of 10 like the rest.
 
Sometimes it takes a bit more work to create the conditions that allow clients to be forthright with us, to develop a culture of feedback in the room. The power disparity combined with any socioeconomic, ethnic, or racial differences make it difficult to tell authority figures that they are on the wrong track. Think about the last time you told your doctor that he or she was not performing well. Clients, however, will let us know subtly on alliance measures far before they will confront us directly.
 
At the end of the third session, the therapist and Sarah reviewed her responses on the SRS. Did she truly feel understood? Was the therapy focused on her goals? Did the approach make sense to her? Such reviews are helpful in fine-tuning the therapy or addressing problems in the therapeutic relationship that have been missed or gone unreported. Sarah, when asked the question about goals, all the while avoiding eye contact and nearly whispering, repeated her desire to be a Miami Heat cheerleader.
 
The therapist looked at the SRS and the lights came on. The slight difference on the goals scale told the tale. When the therapist finally asked Sarah about her goal, she told the story of growing up watching Miami Heat basketball with her dad who delighted in Sarah's performance of the cheers. Sarah sparkled when she talked of her father, who passed away several years previously, and the therapist noted that it was the most he had ever heard her speak. He took this experience to heart and often asked Sarah about her father. The therapist also put the brakes on his efforts to get Sarah to socialize or exercise (his goals), and instead leaned more toward Sarah's interest in cheerleading. Sarah watched cheerleading contests regularly on ESPN and enjoyed sharing her expertise. She also knew a lot about basketball.
 
Sarah's SRS score improved on the goal scale and her ORS score increased dramatically. After a while, Sarah organized a cheerleading squad for her agency's basketball team who played local civic organizations to raise money for the group home. Sarah's involvement with the team ultimately addressed the referral concerns about her social withdrawal and lack of activity. The SRS helps us take clients and their engagement more seriously, like the supershrinks do. Walking the path cut by client goals often reveals alternative routes that would have never been discovered otherwise.
 
Providing feedback to clinicians on the clients' experience of the alliance and progress has been shown to result in significant improvements in both client retention and outcome. “We found that clients of therapists who opted out of completing the SRS were twice as likely to drop out and three times more likely to have a negative outcome.” In the same study of over 6000 clients, effectiveness rates doubled. As incredible as the results appear, they are consistent with findings from other researchers.
 
In a 2003 meta-analysis of three studies, Michael Lambert, a pioneer of using client feedback, reported that those helping relationships at risk for a negative outcome which received formal feedback were, at the conclusion of therapy, better off than 65 percent of those without information regarding progress. Think about this for a minute. Even if you are one of the most effective therapists, for every cycle of 10 clients you see, three will go home without benefit. Over the course of a year, for a therapist with a full caseload, this amounts to a lot of unhappy clients. This research shows that you can recover a substantial portion of those who don't benefit by first identifying who they are, keeping them engaged, and tailoring your services accordingly.
 

The Nuts and Bolts

Collecting data on standardized measures and using what we call 'practice-based evidence' can improve your effectiveness substantially. "Wait a minute," you say, "this sounds a lot like research!" Given the legionary schism between research and practice, sometimes getting therapists to do the measures is indeed a tall order because it does sound a lot like the 'R' word.
 
A story illustrates the sentiments that many practitioners feel about research. Two researchers were attending an annual conference. Although enjoying the proceedings, they decided to find some diversion to combat the tedium of sitting all day and absorbing vast amounts of information. They settled on a hot air balloon ride and were quite enjoying themselves until a mysterious fog rolled in. Hopelessly lost, they drifted for hours until a clearing in the fog appeared finally and they saw a man standing in an open field. Joyfully, they yelled down at the man, "Where are we?" The man looked at them, and then down at the ground, before turning a full 360 degrees to survey his surroundings. Finally, after scratching his beard and what seemed to be several moments of facial contortions reflecting deep concentration, the man looked up and said, "You are above my farm."
 
The first researcher looked at the second researcher and said, "That man is a researcher—he is a scientist!" To which the second researcher replied, "Are you crazy, man? He is a simple farmer!" "No," answered the first researcher emphatically, "that man is a researcher and there are three facts that support my assertion: First, what he said was absolutely 100% accurate; second, he addressed our question systematically through an examination of all of the empirical evidence at his disposal, and then deliberated carefully on the data before delivering his conclusion; and finally, the third reason I know he is a researcher is that what he told us is absolutely useless to our predicament."
 
But unlike much of what is passed off as research, the systematic collection of outcome data in your practice is not worthless to your predicament. It allows you the luxury of being useful to clients who would otherwise not be helped. And it helps you to get out of the way of those clients you are not helping, and connecting them to more likely opportunities for change.
 
First, collaboration with clients to monitor outcome and fit actually starts before formal therapy. This means that they are informed when scheduling the first contact about the nature of the partnership and the creation of a 'culture of feedback' in which their voice is essential.
 
"I want to help you reach your goals. I have found it important to monitor progress from meeting to meeting using two very short forms. Your ongoing feedback will tell us if we are on track, or need to change something about our approach, or include other resources or referrals to help you get what you want. I want to know this sooner rather than later, because if I am not the person for you, I want to move you on quickly and not be an obstacle to you getting what you want. Is that something you can help me with?"
 
We have never had anyone tell us that keeping track of progress is a bad idea. There are five steps to using practice based evidence to improve your effectiveness.
 

Step One: Introducing the ORS in the First Session

The ORS is administered prior to each meeting and the SRS toward the end. In the first meeting, the culture of feedback is continually reinforced. It is important to avoid technical jargon, and instead explain the purpose of the measures and their rationale in a natural commonsense way. Just make it part of a relaxed and ordinary way of having conversations and working. The specific words are not important—there is no protocol that must be followed. This is a clinical tool! Your interest in the client's desired outcome speaks volumes about your commitment to the client and the quality of service you provide.
 
"Remember our earlier conversation? During the course of our work together, I will be giving you two very short forms that ask how you think things are going and whether you think things are on track. To make the most of our time together and get the best outcome, it is important to make sure we are on the same page with one another about how you are doing, how we are doing, and where we are going. We will be using your answers to keep us on track. Will that be okay with you?"
 

Step Two: Incorporating the ORS in the first session

The ORS pinpoints where the client is and allows a comparison for later sessions. Incorporating the ORS entails simply bringing the client's initial and subsequent results into the conversation for discussion, clarification and problem solving. The client's initial score on the ORS is either above or below the clinical cutoff. You need only to mention the client scores as it relates to the cutoff. Keep in mind that the use of the measures is 100-percent transparent. There is nothing that they tell you that you cannot share with the client. It is their interpretation that ultimately counts.
 
"From your ORS it looks like you're experiencing some real problems." Or: "From your score, it looks like you're feeling okay." "What brings you here today?" Or: "Your total score is 15—that's pretty low. A score under 25 indicates people who are in enough distress to seek help. Things must be pretty tough for you. Does that fit your experience? What's going on?"
 
"The way this ORS works is that scores under 25 indicate that things are hard for you now or you are hurting enough to bring you to see me. Your score on the individual scale indicates that you are really having a hard time. Would you like to tell me about it?"
 
Or if the ORS is above 25: "Generally when people score above 25, it is an indication that things are going pretty well for them. Does that fit your experience? It would be really helpful for me to get an understanding of what it is that brought you here now."
 
Because the ORS has face validity, clients usually mark the scale the lowest that represents the reason they are seeking therapy, and often connect that reason to the mark they've made without prompting from the therapist. For example, Matt marked the Individual scale the lowest with the Social scale coming in a close second. As he was describing his problem in public restrooms, he pointed to the ORS and explained that this problem accounted for his mark. Other times, the therapist needs to clarify the connection between the client's descriptions of the reasons for services and the client's scores. The ORS makes no sense unless it is connected to the described experience of the client's life. This is a critical point because clinician and client must know what the mark on the line represents to the client and what will need to happen for the client to both realize a change and indicate that change on the ORS.
 
At some point in the meeting, the therapist needs only to pick up on the client's comments and connect them to the ORS:
 
"Oh, okay, it sounds like dealing with the loss of your brother (or relationship with wife, sister's drinking, or anxiety attacks, etc.) is an important part of what we are doing here. Does the distress from that situation account for your mark here on the individual (or other) scale on the ORS? Okay, so what do you think will need to happen for that mark to move just one centimeter to the right?"
 
The ORS, by design, is a general outcome instrument and provides no specific content other than the three domains. The ORS offers only a bare skeleton to which clients must add the flesh and blood of their experiences, into which they breathe life with their ideas and perceptions. At the moment in which clients connect the marks on the ORS with the situations that are distressing, the ORS becomes a meaningful measure of their progress and potent clinical tool.
 

Step Three: Introducing the SRS

The SRS, like the ORS, is best presented in a relaxed way that is integrated seamlessly into your typical way of working. The use of the SRS continues the culture of client privilege and feedback, and opens space for the client's voice about the alliance. The SRS is given at the end of the meeting, but leaving enough time to discuss the client's responses.
 
"Let's take a minute and have you fill out the form that asks for your opinion about our work together. It's like taking the temperature of our relationship today. Are we too hot or too cold? Do I need to adjust the thermostat? This information helps me stay on track. The ultimate purpose of using these forms is to make every possible effort to make our work together beneficial. Is that okay with you?"
 

Step Four: Incorporating the SRS

Because the SRS is easy to score and interpret, you can do a quick visual check and integrate it into the conversation. If the SRS looks good (score more than 9 cm on any scale), you need only comment on that fact and invite any other comments or suggestions. If the client marks any scales lower than 9 cm, you should definitely follow up. Clients tend to score all alliance measures highly, so the practitioner should address any hint of a problem. Anything less than a total score of 36 might signal a concern, and therefore it is prudent to invite clients to comment. Keep in mind that a high rating is a good thing, but it doesn't tell you very much. Always thank the client for the feedback and continue to encourage their open feedback. Remember that unless you convey you really want it, you are unlikely to get it.
 
And know for sure that there is no 'bad news' on these forms. Your appreciation of any negative feedback is a powerful alliance builder. In fact, alliances that start off negatively but result in your flexibility to client input tend to be very predictive of a positive outcome. When you are bad, you are even better! In general, a score:
  • that is poor and remains poor predicts a negative outcome,
  • that is good and remains good predicts a positive outcome,
  • that is poor or fair and improves predicts a positive outcome even more,
  • that is good and decreases is predictive of a negative outcome.
The SRS allows the opportunity to fix any alliance problems that are developing and shows that you do more than give lip service to honoring the client's perspectives.
 
"Let me just take a look at this SRS—it's like a thermometer that takes the temperature of our meeting here today. Great, looks like we are on the same page, that we are talking about what you think is important and you believe today's meeting was right for you. Please let me know if I get off track, because letting me know would be the biggest favor you could do for me."
 
"Let me quickly look at this other form here that lets me know how you think we are doing. Okay, seems like I am missing the boat here. Thanks very much for your honesty and giving me a chance to address what I can do differently. Was there something else I should have asked you about or should have done to make this meeting work better for you? What was missing here?"
 
Graceful acceptance of any problems and responding with flexibility usually turns things around. Again, clients reporting alliance problems that are addressed are far more likely to achieve a successful outcome—up to seven times more likely! Negative scores on the SRS, therefore, are good news and should be celebrated. Practitioners who elicit negative feedback tend to be those with the best effectiveness rates. Think about it—it makes sense that if clients are comfortable enough with you to express that something isn't right, then you are doing something very right in creating the conditions for therapeutic change.
 

Step Five: Checking for change in subsequent sessions

With the feedback culture set, the business of practice-based evidence can begin, with the client's view of progress and fit really influencing what happens. Each subsequent meeting compares the current ORS with the previous one and looks for any changes. The ORS can be made available in the waiting room or via electronic software (ASIST) and web systems (MyOutcomes.com). Many clients will complete the ORS (some will even plot their scores on provided graphs) and greet the therapist already discussing the implications. Using a scale that is simple to score and interpret increases client engagement in the evaluation of the services. Anything that increases participation is likely to have a beneficial impact on outcome.
 
The therapist discusses if there is an improvement (an increase in score), a slide (a decrease in score), or no change at all. The scores are used to engage the client in a discussion about progress, and more importantly, what should be done differently if there isn't any.
 
"Your marks on the personal well-being and overall lines really moved—about 4 cm to the right each! Your total increased by 8 points to 29 points. That's quite a jump! What happened? How did you pull that off? Where do you think we should go from here?"
 
If no change has occurred, the scores invite an even more important conversation.
 
"Okay, so things haven't changed since the last time we talked. How do you make sense of that? Should we be doing something different here, or should we continue on course steady as we go? If we are going to stay on the same track, how long should we go before getting worried? When will we know when to say 'when?' "
 
The idea is to involve the client in monitoring progress and the decision about what to do next. The discussion prompted by the ORS is repeated in all meetings, but later ones gain increasing significance and warrant additional action. We call these later interactions either checkpoint conversations or last-chance discussions. In a typical outpatient setting, checkpoint conversations are conducted usually at the third meeting and last-chance discussions are initiated in the sixth session. This is simply saying that based on over 300,000 administrations of the measures, by the third encounter most clients who do receive benefit from services usually show some benefit on the ORS; and if change is not noted by meeting three, then the client is at a risk for a negative outcome. Ditto for session six except that everything just mentioned has an exclamation mark. Different settings could have different checkpoints and last-chance numbers. Determining these highlighted points of conversation requires only that you collect the data. The calculations are simple and directions can be found in our book, The Heroic Client. Establishing these two points helps evaluate whether a client needs a referral or other change based on a typical successful client in your specific setting. The same thing can be accomplished more precisely by available software or web-based systems that calculate the expected trajectory or pattern of change based on our data base of ORS administrations. These programs compare a graph of the client's session-by-session ORS results to the expected amount of change for clients in the data base with the same intake score, serving as a catalyst for conversation about the next step in therapy.
 
If change has not occurred by the checkpoint conversation, the therapist responds by going through the SRS item by item. Alliance problems are a significant contributor to a lack of progress. Sometimes it is useful to say something like, "It doesn't seem like we are getting anywhere. Let me go over the items on this SRS to make sure you are getting exactly what you are looking for from me and our time together." Going through the SRS and eliciting client responses in detail can help the practitioner and client get a better sense of what may not be working. Sarah, the woman who aspired to be a Miami Heat cheerleader, exemplifies this process.
 
Next, a lack of progress at this stage may indicate that the therapist needs to try something different. This can take as many forms as there are clients: inviting others from the client's support system, using a team or another professional, a different approach; referring to another therapist, religious advisor, or self-help group—whatever seems to be of value to the client. Any ideas that surface are then implemented, and progress is monitored via the ORS. Matt and the idea of encouraging his anger illustrate this kind of discussion.
 

The Importance of Referrals

If the therapist and client have implemented different possibilities and the client is still without benefit, it is time for the last-chance discussion. As the name implies, there is some urgency for something different because most clients who benefit have already achieved change by this point, and the client is at significant risk for a negative conclusion. A metaphor we like is that of the therapist and client driving into a vast desert and running on empty, when a sign appears on the road that says 'last chance for gas.' The metaphor depicts the necessity of stopping and discussing the implications of continuing without the client reaching a desired change.
 
This is the time for a frank discussion about referral and other available resources. If the therapist has created a feedback culture from the beginning, then this conversation will not be a surprise to the client. There is rarely justification for continuing work with clients who have not achieved change in a period typical for the majority of clients seen by a particular practitioner or setting.
 
Why? Because research shows no correlation between a therapy with a poor outcome and the likelihood of success in the next encounter. Although we've found that talking about a lack of progress turns most cases around, we are not always able to find a helpful alternative.
 
“Where in the past we might have felt like failures when we weren't being effective with a client, we now view such times as opportunities to stop being an impediment to the client and their change process.” Now our work is successful when the client achieves change and when, in the absence of change, we get out of their way. We reiterate our commitment to help them achieve the outcome they desire, whether by us or by someone else. When we discuss the lack of progress with clients, we stress that failure says nothing about them personally or their potential for change. Some clients terminate and others ask for a referral to another therapist or treatment setting. If the client chooses, we will meet with her or him in a supportive fashion until other arrangements are made. Rarely do we continue with clients whose ORS scores show little or no improvement by the sixth or seventh visit.
 
Ending with clients who are not making progress does not mean that all therapy should be brief. On the contrary, our research and the “findings of virtually every study of change in therapy over the last 40 years provide substantial evidence that more therapy is better than less therapy for those clients who make progress early in treatment” and are interested in continuing. When little or no improvement is forth coming, however, this same data indicates that therapy should, indeed, be as brief as possible. Over time, we have learned that explaining our way of working and our beliefs about therapy outcomes to clients avoids problems if therapy is unsuccessful and needs to be terminated.
 
Barry Duncan writes: But it can be hard to believe that stopping a great relationship is the right thing to do.
 
Alina sought services because she was devastated and felt like everything important to her had been savagely ripped apart—because it had. She worked her whole life for but one goal, to earn a scholarship to a prestigious Ivy-league university. She was captain of the volleyball team, commanded the first position on the debating team, and was valedictorian of her class. Alina was the pride of her Guatemalan community—proof positive of the possibilities her parents always envisioned in the land of opportunity. Alina was awarded a full ride in minority studies at Yale University. But this Hollywood caliber story hit a glitch. Attending her first semester away from home and the insulated environment in which she excelled, Alina began hearing voices.
 
She told a therapist at the university counseling center and before she knew it she was whisked away to a psychiatric unit and given antipsychotic medications. Despondent about the implications of this turn of events, Alina threw herself down a stairwell, prompting her parents to bring her home. Alina returned home in utter confusion, still hearing voices, and with a belief that she was an unequivocal failure to herself, her family, and everyone else in her tightly knit community whose aspirations rode on her shoulders.
 
Serendipity landed Alina in my office. I was the twentieth therapist the family called and the first who agreed to see Alina without medication. Alina's parents were committed to honor her preference to not take medication. We were made for each other and hit it off famously. I loved this kid. I admired her intelligence and spunk in standing up to psychiatric discourse and the broken record of medication. I couldn't wait to be useful to Alina and get her back on track. When I administered the ORS, Alina scored a 4, the lowest score I'd ever had.
 
We discussed her total demoralization and how her episodes of hearing voices and confusion led to the events that took everything she had always dreamed of from her—the life she had worked so hard to prepare for. I did what I usually did that is helpful—I listened, I commiserated, I validated, and I worked hard to recruit Alina's resilience to begin anew. But nothing happened.
 
By session three, Alina remained unchanged in the face of my best efforts. Therapy was going nowhere and I knew it because the ORS makes it hard to ignore—that score of 4 was a rude reminder of just how badly things were going.
 
At the checkpoint session, I went over the SRS with her, and unlike many clients, Alina was specific about what was missing and revealed that she wanted me to be more active, so I was. She wanted ideas about what to do about the voices, so I provided them—thought stopping, guided imagery, content analysis. But, no change ensued and she was increasingly at risk for a negative outcome. Alina told me she had read about hypnosis on the internet and thought that might help. Since I had been around in the '80s and couldn't escape that time without hypnosis training, I approached Alina from a couple of different hypnotic angles—offering both embedded suggestions as well as stories intended to build her immunity to the voices. She responded with deep trances and gave high ratings on the SRS. But the ORS remained a paltry 4.
 
At the last-chance conversation, I brought up the topic of referral but we settled instead on a consult from a team (led by Jacqueline Sparks). Alina, again, responded well, and seemed more engaged than I had noticed with me—she rated the session the highest possible on the SRS. The team addressed topics I hadn't, including differentiation from her family, as well as gender and ethnic issues. Alina and I pursued the ideas from the team for a couple more sessions. But her ORS score was still a 4.
 
Now what? We were in session nine, well beyond how clients typically change in my practice. After collecting data for several years, I know that 75 percent of clients who benefit from their work with me show it by the third session; a full 98 per cent of my clients who benefit do it by the sixth session. So is it right that I continue with Alina? Is it even ethical?
 
Despite our mutual admiration society, it wasn't right to continue. A good relationship in the absence of benefit is a good definition of dependence. So I shared my concern that her dream would be in jeopardy if she continued seeing me. I emphasized that the lack of change had nothing to do with either of us, that we had both tried our best, and for whatever reason, it just wasn't the right mix for change. We discussed the possibility that Alina see someone else. If you watch the video, you would be struck, as many are, by the decided lack of fun Alina and I have during this discussion.
 
Finally, after what seemed like an eternity, including Alina's assertion that she wanted to keep seeing me, we started to talk about who she might see. She mentioned she liked someone from the team, and began seeing our colleague Jacqueline Sparks.
 
By session four, Alina had an ORS score of 19 and enrolled to take a class at a local university. Moreover, she continued those changes and re-enrolled at Yale the following year with her scholarship intact! When I wrote a required recommendation letter for the Dean, I administered the ORS to Alina and she scored a 29. By my getting out of her way and allowing her and myself to 'fail successfully,' Alina was given another opportunity to get her life back on track—and she did. Alina and Jacqueline, for reasons that escape us even after pouring over the video, just had the right chemistry for change.
 
This was a watershed client for me. Although I believed in practice-based evidence, especially how it puts clients center stage and pushes me to do something different when clients don't benefit, I always struggled with those clients who did not benefit, but who wanted to continue with me nevertheless. This was more difficult when I really liked the client and had become personally invested in them benefiting. Alina awakened me to the pitfalls of such situations and showed a true value-added dimension to monitoring outcome—namely the ability to fail successfully with our clients. Alina was the kind of client I would have seen forever. I cared deeply about her and believed that surely I could figure out something eventually.
 
But such is the thinking that makes 'chronic' clients—an inattention to the iatrogenic effects of the continuation of therapy in the absence of benefit. Therapists, no matter how competent or trained or experienced, cannot be effective with everyone, and other relational fits may work out better for the client. Although some clients want to continue in the absence of change, far more do not want to continue when given a graceful way to exit. The ORS allows us to ask ourselves the hard questions when clients are not, by their own ratings, seeing benefit from services. The benefits of increased effectiveness of my work, and feeling better about the clients that I am not helping, have allowed me to leave any squeamishness about forms far behind.
 
Practice-based evidence will not help you with the clients you are already effective with; rather, it will help you with those who are not benefiting by enabling an open discussion of other options and, in the absence of change, the ability to honorably end and move the client on to a more productive relationship. The basic principle behind this way of working is that our day-to-day clinical actions are guided by reliable, valid feedback about the factors that account for how people change in therapy. These factors are the client's engagement and view of the therapeutic relationship, and—the gold standard—the client's report of whether change occurs. Monitoring the outcome and the fit of our services helps us know that when we are good, we are very good, and when we are bad, we can be even better.

A Crash Course in Psychotherapy: Moving through Anxiety and Self-Doubt

Posted on by rezendevknowfully.com
"There is a way out," I couldn't help telling myself as I imagined the door to the small clinic office behind me. The room held nothing but two mismatched office chairs, a window with half-retreated, yellowing blinds, and the heavy smell of sweat, carpet cleaner and someone's lunch. My stomach was tied in knots, and air flowed in and out of my nose surprisingly easily, the way it always seemed to when my heart picked up its pace and my sinuses cleared in response.
 
There was no room in that cramped office for a break: no way Sam* and I could stretch our legs, distract ourselves by staring at titles on a bookcase, or recline in our chairs and close our eyes. There were just two feet of space between us, and I cringed at the thought of moving and accidentally having our knees bump. It was just us—his regretful disclosure, and my words that brought no comfort—that I had to be with, unless I bolted out that door.
 
I remember the simple instruction that was given to us psychotherapy interns during orientation week: Always sit in the chair closest to the door so you have a way out if your client places you in danger. This was a surprising prospect for me, a 25-year-old first-year therapist still in graduate school, who chose to work at an outpatient LGBT community mental health clinic. I pictured myself with clients struggling to come out to family and friends, coping with the loss of a loved one, or needing to heal from childhood trauma. This was, in fact, the case. But it was also the case that I would see clients who suffered paranoia, borderline personality disorder and severe post-traumatic stress disorder. “This is the way it works in the mental health field—the least experienced get assigned the most severely disordered and challenging clients”, whereas the seasoned therapists get to pick their client load, and more often than not, it seemed, stick to young women with relationship problems.
 
I stayed in that clinic office with Sam, because if I didn't, what was I proving to myself? What was I proving to my client? I could make it through this. He could make it through this. There was no physical danger, only a danger that I sensed we both felt coming from inside ourselves, screaming to us through our blood and pounding down on our chests. But this danger felt more difficult to conquer, because the perpetrator was all around and nowhere at once.
 

Sam

Two months after I started my internship, my clinical supervisor and I did an intake with Sam, who I was scheduled to see weekly for psychotherapy. In Sam's intake, he volunteered very little about himself. The soft lines around his eyes and mouth told me he was in his mid-30s, and he wore jeans and a flannel shirt. He didn't look at all like the gay men who worked at the clinic, with their pressed button-down shirts and neatly gelled hair, or the preppy Castro-neighborhood dwellers wearing pastel shirts with the collars up, tight designer jeans and Ray-Ban sunglasses. Sam came in carrying a skateboard and a messenger bag. His narrow, stubble-covered face was topped with a mess of light brown hair, and his Levi's seemed to almost fall off his scrawny body.
 
Sam refused to give us his last name, and the stiffness in his body turned to agitation when my supervisor and I asked him about his family history. "I don't understand why you need to know this," he told us, his eyes shifting around the room and his arms crossed tightly in front of his chest. We told him he didn't have to tell us anything he didn't want to—something I would find myself saying to him many times throughout our six months working together. I discovered later that day that he had disclosed more on the intake form than the interview. “The three fractured sentences he wrote under the History section spoke volumes: "Sexually abused as a kid. A lot. Don't know how many times."”
 
I already knew from his intake that Sam would be a challenge to work with. But when Sam told my clinical supervisor that he wanted to have her as his therapist instead of me, I knew I would be in for a rocky ride, and I would have to prove to Sam, despite my inexperience, that I had the clinical expertise to help him. I thought it would be easier to talk to Sam with my supervisor out of the room, and hoped he would feel safer that way since it would be just one—not two—therapists to contend with.
 
We spent the first therapy sessions with me mostly asking questions and him answering. Moments of silence brought his body to shift in his chair and his eyes to stare wide at the door, so I kept the conversation going any way I could. He told me about his boyfriend and the problems they were having. He recalled fits of anger toward his boyfriend that seemed to come from nowhere, and anxiety attacks at bars and parties. But I could see that something much darker and scarier lurked under Sam's surface and controlled his life. He continued to refuse discussion about his family and childhood, and even benign-sounding questions like "Where were you born?" would lead Sam to erect a wall of fear and anxiety between us. "I don't want to talk about it," he would say, his face turning white, his expression cold and serious. "Okay," I nodded, keeping my tone calm and even, and moved the conversation back to the present.
 

Beneath the Surface

The truth is I wasn't calm. I dreaded every session with Sam. I felt inadequate to deal with what lurked under the surface, and felt responsible for the tenseness between us. I had received basic clinical training on working with trauma survivors in school. I knew it was important to move slowly with Sam and not let too much be revealed at once, because the memories of his past could overwhelm him. But I felt like the therapy was moving too slowly, and that I wasn't reaching him at all.
 
Like a lot of new therapists, I was hard on myself. I pushed myself to be the kind of therapist Sam wanted and needed. His case consumed my thoughts: “I fantasized about having a breakthrough moment with him, where he would finally relax into our sessions and open up to me, and I would guide him through reclaiming his painful past with perfect expertise and confidence.” I often spent my entire supervision hour consulting on his case and brought what I had learned into our sessions. I taught Sam practical techniques to get a handle on his anxiety, and new ways to open up discussions with his boyfriend. I was doing the best job I could as his therapist. But the problem was, neither Sam nor I could see this.
 
About a month into his treatment, Sam came into session frustrated and anxious. He and his boyfriend had been fighting all week and were considering breaking up. When my empathic words like, "That sounds really painful," fell short of what he wanted, he turned the conversation to discuss me. He explained to me all the reasons why I was not a good enough psychotherapist: I was too young. I was inexperienced. I didn't look like what therapists are supposed to look like. I had no clinical specialty in trauma. I had no list of degrees. I wasn't a gay man.
 
I didn't know what to do other than take in all that he was saying about me. My face and body remained calm as I mentally halted the oncoming surge of panic, heat and tears about to erupt from my gut. I told him he was entitled to his feelings and opinions. I couldn't refute his accusations because they were, in fact, all true.
 
After he left the clinic, I grabbed my own belongings and sped through the clinic doors as fast as I could. I needed air and it felt as if the clinic itself were choking me. As soon as a cool San Francisco December breeze hit my face, my skin began to crawl and my stomach, arms and legs, and even my blood all felt suddenly, completely wrong. “I felt like there was a monster inside of me, and that I would soon be exposed for who I really was.” I needed to hide, and as I hurried home through the streets of the Mission District, I envisioned myself as a snake, searching for a rock to slither under.
 
Being in this state made me recall something I was currently learning about in my Severe Psychopathology class: the psychoanalytic defense mechanism called projective identification. I thought about how Sam couldn't tolerate his feelings of shame, fear, and disgust, and so was unconsciously transferring them to me. I learned that, ideally, the therapist is supposed to process these emotions to a tolerable state and return them to the patient. But I didn't know what to do with all these feelings; I didn't know how to process them and return them to him. The concept of projective identification gave me a framework to understand what was going on between Sam and me, but did not help me move through this impasse between us. I felt stuck and overwhelmed with his feelings, and unfortunately my defense mechanism of choice—analyzing, diagnosing and intellectualizing the problem—did not bring me peace of mind.
 
During the next few days my behaviors began to resemble the serious psychopathology of Sam and some of my other clients. I was hyper-aware of my surroundings all the time and hated leaving my home. When a friend coaxed me to go with her to a holiday party, I entered the house to find a kitchen full of acquaintances staring at me. “I was convinced they all knew Sam, and Sam had told them about what a terrible therapist I was. My dirty secret was out.”
 
When I peeked down the hallway I saw that the living room was full of more people lounging on couches, leaning against walls and chatting. I heard a mix of voices muddled together and I strained to pull Sam's out of it. I was convinced he was in that room talking to people I knew, even though as far as I was aware, we had no friends in common. It felt wrong for me to be at this party. I feared I would be called out: how dare I go somewhere Sam might be and put him in that terribly awkward position of seeing his therapist—his bad therapist—in public! I gave my friend who brought me there a quick goodbye, slid out of the house without anyone noticing, and hurried back home.
 
Sam couldn't tell me about his past, and about the horrible things that had happened to him. These feelings that were now overwhelming me were all I had to go on, and were the only hints about what he might be struggling with everyday.
 

Fight, Flight or Freeze?

It would be three weeks before I saw Sam again. He and I both left town for the holidays, and it was definitely a welcome break. When our next session approached, I began to panic. "I don't want to see him anymore. We're not a good match. I need another week. I'm not ready!" I told my supervisor in long, desperate attempts to cancel the session. I wanted someone, anyone, to tell me I could end the therapy with him. I wanted to be told that he was abusing me, that I shouldn't take it, and that I was unsafe.
 
My supervisor, professors and colleagues all empathized, but pushed me to continue seeing Sam. "You need to go back in that clinic room with him for you, not him," they told me. "You need to prove to yourself that you aren't going to let him run you down." I cried. I protested, and I fought it to the very end. But ultimately, I knew they were right. And so it brought me to this moment with him, locked in struggle, a wound exposed, and only myself to hold onto.
 
Sam arrived fifteen minutes late to the session, which wasn't unusual for him. I was somewhat surprised he showed at all and wondered, If he thinks I am such a bad therapist, why is he still coming to the sessions? His expression was cold and he refused to make eye contact. He began speaking almost immediately, and recounted a recent sexual experience he had with his boyfriend the night prior. As the story went on, it became quite graphic and disturbing. Sam described feeling pressured into doing something sexual he didn't want to do. He described freezing and not being able to stop it as it was happening. He was crying and I was startled by the sexual details I was hearing. There was something in me that knew that what he was doing—confessing this painful experience to me—was too sudden. My gut, along with words from the textbook on trauma lodged in my brain, were telling me the same thing: this could overload him. But at the same time, another part of me felt relieved that he was opening up to me and trusting me with the story. Was this the breakthrough moment I had been waiting for?
 
Everything moved quickly. Then, before I fully knew what was happening, he turned his face to me. His crying slowed to sniffles, and he squinted as if to focus and find something deep in my eyes. “His chin wrinkled and quivered as he said, "Now I feel like garbage—what are you going to do about it?"”
 
There was no rock for me to climb under. I had to stay there in that moment. And I had to respond.
 
"I wish there were something I could do to make the pain go away, but there isn't. I'm sorry that happened to you, and all I can do is be here with you through it."
 
"Sorry? You're sorry? That's bullshit!" he said, shifting back and forth in his seat, grabbing his hair with one hand and grinding the other one into the arm of the chair. "How can you just sit there and let me feel this way? How can you make me tell you that—make me feel so disgusting—then not do anything about it?"
 
Everything in the room came into micro-focus, and I felt pressed up against it all, like I was trying to push time forward more quickly to get out of the nightmare erupting around me. I thought about the door. I thought about what everyone told me—that I needed to get through this for me. I knew I couldn't make him feel better. I couldn't erase what had happened to him 30 years ago or the night before. I couldn't take away the pain he felt because of it. I couldn't soothe him—he wouldn't have let me even if I tried. “As his anger and accusations continued to fill the room, I repeated the only honest words I knew: "I'm sorry, there's nothing I can say to you right now that's going to make you feel better."”
 
As our 50-minute time slot came to a close, he became silent for a few moments, exhausted, with nothing else to say. Then, as if he had been watching the clock for when the second hand hit the mark, he hastily grabbed his bag, wiped his face and left the office. I didn't want to move, because moving would stir all the feelings inside me that I knew would soon erupt. I felt like I had been run over by a truck—flattened and broken. But I was alive; I could see and feel that much.
 
Finally I had to get up and leave the office because another therapist had reserved the next time slot. I went downstairs to the intern room. June, an intern in her sixties, was there doing paperwork. She read the destruction on my face immediately. "Are you okay?" she asked softly. I exploded into tears, and she wheeled her chair toward me and hugged me. I cried on her shoulder like a child who had just been beat up by a bully, crying to her mother.
 
"What's happening? What's going on?" Her eyebrows lowered, and her tone remained soft and calm, but concerned. June already knew about Sam, and had heard me process my sessions with him in group supervision, so she wasn't surprised when I told her everything that happened in the session, including what Sam said and all my responses to him.
 
"You said that? You said those things?" June perked up.
 
"Yes," I said, expecting criticism. But instead a smile broke across her face.
 
"It sounds like you did the right thing."
 
"I did?" I said, coming out of my sniffles, feeling somewhat pessimistic but more hopeful.
 
"Yeah, I don't know what I would have said . . . I mean, what else could you have said?"
 
"I don't know, but . . ." I trailed off, not knowing the end of my thought.
 
"Seriously," she repeated, "what else could you have done?"
 
I wanted to give her an answer that provided hard evidence against me: an analysis of the conversation that showed where I'd messed up and what I could have said and done differently that would have left Sam, and me, in a better place. I wanted to prove to her that I was not the right woman for the job.
 
"Not be his therapist?" I finally responded, hearing the desperation and uncertainty of my words, and realizing for the first time that I could not stay in this place any longer—needing other people to show me the way, trying to find a way out, and wanting to be someone else.
 
June laughed, threw up her arms and gave me another hug. "You'll be okay," she said. I began to laugh with her, because she was right: I was okay. In that session with Sam, I hadn't tried to escape. I'd stayed with myself, as scary as it was, and it hadn't destroyed me.
 

Truths Revealed

Something shifted in me after that. I felt like I'd won a battle, and I was proud of myself. I was tired of the fear and the self-criticism. I began to see the fruits of my labor with my other clients as they all made progress in their therapy, and I realized that I could be and was a good therapist. I began to see that “being a good therapist was not about being a punching bag or taking on my clients' pain, but about making my clients responsible for their feelings and behaviors.” I was not there to save anyone; I was there to help people help themselves, and even then, only if they would let me.
 
Something changed in Sam, as well. The next week when he came in for his session, he kept his head turned down and looked up at me with wide eyes, half smiling, searching my face again for something, but this time it was approval.
 
"Hey, I'm sorry for the way I acted last week," he said. "I guess I was pretty mean, huh."
 
"Thanks for your apology. I think last week was a challenge for both of us." I paused at this and he continued to look at me with wide eyes, now a little nervous. So I continued, "I have to be honest with you—you have definitely been a challenge for me to work with. I've spent a lot of time thinking about our sessions, and received a lot of guidance from my supervisor, and I think I've done the best I can."
 
"I think so, too . . . but the thing is . . ." I could see Sam searching for his words carefully as his eyes didn't move from one spot on the wall, "I guess I just can't trust you."
 
"Because of my age, level of experience, and stuff?" I replied easily, now feeling confident and relaxed.
 
"Yeah. To me, you're just not who my therapist is supposed to be."
 
"If that's the case, why do you keep coming back to see me?"
 
Sam paused at this and looked at the floor, rubbing the back of his head with his hand. "I don't know. I guess I didn't think I had a choice."
 
"You do have a choice, Sam."
 
"What is it? What's my choice?"
 
"You can continue to see me at this agency, or you can find a different therapist at a different agency."
 
"Like where?"
 
"If you decide that's what you want, I can give you some resources."
 
"Can you call them for me? Or can we call them together?" His leg shook as he spoke.
 
"No, you'll need to set it up yourself. I can't do the work for you."
 
At this he seemed satisfied. He made the decision to find a different therapist, and I followed through on giving him some resources. I realized that, had I been more seasoned and further along in my career as a therapist, things might have turned out differently. Perhaps I would have questioned his assumptions of who his therapist was "supposed to" be, and urged him to stick through it with me. But “as a new therapist, I looked truthfully at my limitations with a dose of self-empathy.” I also relished the huge wave of relief that washed over me after Sam made his decision. And so I felt satisfied with his decision, as well. I was helping him take responsibility for his care, as well as his feelings.
 
Within just a couple of weeks, Sam set up his therapy at an agency that specialized in trauma work. Despite the fact that he had already completed his intake and was about to start seeing a therapist weekly, he told me he wanted to continue our sessions, as well. I told him this wasn't going to be possible, since it is counter-productive to see two individual therapists at the same time. I was also curious about his desire to continue to see me, after all that he had said about me not being able to help him. So I asked him about it:
 
"Sam, why would you want to continue therapy with me since you say you can't trust me, and you have another therapist that you think you will be able to trust more?"
 
"Well . . ." he said, "you have been helpful in some ways."
 
"In what ways?"
 
"Well, like I learned how to be able to notice what happens to me before I have a panic attack, so I can stop them from happening…"
 
I nodded.
 
"And I learned how to talk to my boyfriend when I'm upset instead of letting it build up into an explosion." He looked at me matter-of-factly, like it was not new information, and not strange or surprising for me to hear that I had, in fact, helped him.
 
A part of me was tempted to bring this contradiction to his attention and say something like, "So, who's the inadequate therapist, now?" But I held my tongue. I didn't need to prove myself to him or any other client any longer.
 
Instead I smiled and said, "I'm glad I could help."
 

After the Crash, Moving Forward

“My six-month therapy with Sam, as difficult and painful as it was at times, turned out to be a crash course on becoming a therapist.” It taught me profound lessons about what my role as the therapist was, and how to sit with some of the most difficult material and still hold onto myself.
 
A year later, I saw how I had grown as a therapist from this experience. During a clinical internship in the counseling department of a Bay Area high school, I met with a student, Linda, who was in the acute phase of post-traumatic stress disorder. A few months prior, Linda had been kidnapped and raped on her way home from school. I passionately wanted to help Linda and my heart brimmed with empathy.
 
However, like Sam, Linda rejected my empathy. When I asked her questions, any questions, she would immediately tear and tense up.
 
"Please don't ask me about what happened. Please don't make me talk about it," she sobbed and quivered. Her body folded in on itself as she brought her knees and arms to her chest in the small plastic chair. I immediately thought of Sam.
 
"No one is going to make you talk about it. You can talk about whatever you want."
 
These words, and any other words from me, didn't calm her. In fact, it was clear that, from week to week, her anxiety in my office was getting worse. One week, her fear turned to anger:
 
"You're making me come here and talk to you, and I hate it! I don't want to talk to you! Stop making me talk to you!" Her body shook with fear and her eyes pierced me. I felt her anger come toward me, but I also recognized the fear that encased her body, so I didn't absorb the blame from her accusations.
 
"Linda, no one is making you do anything. You don't have to come to these meetings. It's your choice. I know you are very scared right now and I want to help you."
 
Linda continued to sob, and then, with her eyes to the floor, said in a very soft voice, "I don't want to come here anymore."
 
Linda was not ready to face the horrible demons terrorizing her. I didn't blame myself for this, nor did I take her demons on for her. I refused to cooperate with Linda's projection of me as the bad guy and helped empower her to take responsibility for what she was feeling.
 
I also knew how badly she needed help. So I asked her for one final request: could I speak to her and her mother together? Linda agreed, and I set up a meeting. Her mother poured her heart out to me about how sad she felt for her daughter, and the two of them cried and held each other together in my office. I explained to them both the symptoms and ramifications of PTSD. While Linda's eyes shifted around the room as if her mind was somewhere else, her mother listened closely to my urge to get her daughter help.
 
I left it up to Linda to contact me if she wanted to see me again, with or without her mother. I knew this would be the only way she would feel an ounce of safety in my office. However, I never heard from her again. “This time I knew that even the most skilled therapist in the world can't help someone if they don't want to be helped.” And I felt peace of mind knowing that I did all I could do: reach a safe, confident and competent hand out to Linda.
 

The Hard Way

Nothing I learned in any of my graduate classes could have prepared me for the emotional experience of being a new therapist. As they say, it is one of those things a person has to learn the hard way. Many of the difficult emotions I felt were due to a complex combination of my clients' and my own personal experiences in the world. But the self-doubt and fear were universal and part of the first developmental phase of becoming a therapist. True confidence comes with time and experience, and will only come when we dare to test ourselves and allow our clients to move us in profound ways.
 
*All names and identifying information of the clients and psychotherapists have been changed to protect confidentiality.

Family Therapy with Families Facing Catastrophic Illness: Building Internal and External Resources

Posted on by rezendevknowfully.com

Ten years ago my late husband Ronald William Pulleyblank, with the help of his doctor and with a small group of witnesses, had his ventilator turned off, after living on it for seven years. Those years and the ones since then have radically affected my life and my work as a psychologist. Ten years after his death, twenty-five family and friends dedicated a redwood tree in Ron's name. In this beautiful event, after so long, we were able to place his illness and death back in what Lawrence Langer calls chronological time.

Langer, in his book, The Holocaust, distinguishes between two kinds of time: chronological time and durational time. He says that we expect a life in chronological time, made up of a past, present and future. When crises become the norm of life, durational time sets in. This is time without past or future and with a recurring experience of a disturbing present that is difficult to organize, express or forget. Langer writes that because durational time cannot overflow the blocked reservoir of its own moment it never enters what we usually experience as the stream of time. Often we and the people around us expect our grief to last for a prescribed length of time. Depending on the level of stress during an illness, this experience can last for much longer than we would expect. This assumption and others often need to be challenged, if patients and families are to find ways to live with significant illness.

 

Challenged Assumptions, Dilemmas, Necessary Conversation

1. Assumption: We each are responsible for ourselves and must make decisions for ourselves.
 
The Dilemma: A particular illness belongs to the patient. How the patient perceives this illness often determines the decisions he or she wishes to make. At the same time the perception of the illness is often quite different for family members who are responsible for the patient's care.
 
An example: Harry, who is very ill, continues to want to drive his children to school. His wife fears that his illness makes it unsafe.
 
Necessary conversations: The couple has to reassess which decisions are independent decisions and which must now be mutual. The roles and the responsibilities in their household also must be reassessed. These conversations need to include the multiple perspectives of all family members and sometimes those of extended family, caregivers and the norms of the community in which they live. The tendency to focus on the needs of the patient over the needs of caregivers and family members often must be challenged.
 
Note: Who participates in these conversations, and in fact in all conversations, often depends upon cultural values and beliefs. Before developing a treatment plan, an assessment with the family of how decisions are to be made is essential.
 

Positive Choices

2. Assumption: There are always positive choices to make, actions to take.
 
Dilemma: Often outcomes about the course of an illness are unknown. Tolerating ambiguity is a prerequisite for making decisions.
 
Example: A patient has fast-growing prostate cancer. He has the choice of following a usual course of treatment with mixed outcomes or an experimental treatment with little or no clear outcome data.
 
Necessary Conversations: Family members work to increase their tolerance of stressful emotional states due to ambiguity. They examine strategies and past experience that may help them tolerate the unknown.
 

Family Resources

3. Assumption: We often hold the belief that each family should and can provide for ill family members.
 
Dilemma: Due to the complexity of treatment and duration of treatment, there is often too much stress on family resources. This can overload the system and make it impossible for one family to provide physical, emotional, spiritual, social and financial resources adequate for all family members.
 
Examples: There is an extremely high divorce rate in families with long-term illnesses and also a high illness rate in other family members.
 
Necessary Conversations: The family explores how to build a community of support. With this support they learn ways to advocating for the needs of all family members in the family and in the wider community vs. over-relying on already overwhelmed family resources.

Maintaining Life

4. Assumption: It is the job of the medical establishment to maintain life.
 
Dilemma: Though this is a central tenet of medical practice, maintaining care is not the direct responsibility of the medical world. Separation between medical decisions in emergency rooms and the implications for life following these decisions can lead to patients being kept alive beyond their capacity to enjoy life and the capacity of their families to sustain them. As part of this dilemma, there is a medical process in place to save lives, but often no ethical process in place that offers the patient and family members a voice in deciding when enough is or is not enough. In addition to life-threatening issues, realistic care plans that take into account family resources need to be part of the medical treatment plan.
 
Necessary Conversations: Family discussions before there is an emergency about how decisions ought to be made can be very helpful. Though health-care directives are useful in this regard, they need to be re-assessed as the situation changes. Convening multiple systems that impact family life so that there is a shared understanding of what is possible and what are the wishes of the family will sometimes address issues of fragmentation that lead to unwanted decisions. Integration of services also adds to the possibilities that families have of accessing needed resources.
 

Treatment Principles

Underlying these conversations are the principles of therapy, or the backdrop of any engagement in the treatment process described below:
 
Shared human experience: No one avoids illness and death. It is an experience that bridges, by its very nature, the therapist/client relationship; therefore our capacity to be seen is crucial in entering the often lonely experience of illness and death.
 
Spiritual Practice: Thinking of the therapy room or someone's home as a sacred space. Evoking the strength of prayer, meditation, not being afraid to ask for help in facing the unknown. Starting with silence, leaving time for meditation ending with silence. Sharing one's own spiritual practice and prayer.
 
A Narrative Overlay: Arthur Frank, in his article about illness and deep listening, describes three different kinds of stories related to serious illness. They are: Restitution Stories in which there is a positive resolution (this kind is a favorite of us therapists), Chaos Stories in which things remain ambiguous (our least favorite kind), and Quest Stories in which the exploration of the unknown is a goal of the therapy.
 
Social Activism: Patients are often marginalized. They are a group fighting not to be silenced, and part of the therapy is advocating with them for their rights.
 

Examples of Treatment Issues at Different Stages of Illness

At diagnosis: Keeping things the same—a wish not to tell. A man 77 years old is diagnosed with fast-growing prostate cancer. He is experiencing a profound sense of disbelief because, though he has been having difficulty with urination, he has been told over the last three years that this is normal. He's also been told that if he does have prostate cancer it is most likely to be slow moving and he will die of something else. No tests are done until very recently, when it is discovered that the cancer is fast-moving and advanced. While he is dealing with this disbelief, he has at the same time to decide about whether or not to choose the conventional treatment or an experimental treatment, and where to get treatment. His children are scattered. His wife is highly anxious and wants a decision to be made immediately. He wants to go slowly, still focused on his disbelief that the doctors he had had faith in seemed to have made a mistake in his case. His focus is on keeping things the same. His wife's focus is on fixing things. Slowly his adult children, who up until this time have never participated in their parents' decision-making process, join their parents in making a decision—the best decision that they can make, but still a decision with uncertainty. In this family, this has a surprising enlivening effect as if everyone knows that they don't know what will happen, and so they reach out to each other and build on the strengths of their relationships.
 
Note: There are many reasons for patients and families to wish not to speak of illness. It often creates a sense of isolation as one is seen as different. It can be seen as weakening. Around particular illnesses there are many fears and judgments. Communicating about illness can have negative effects on employment and parenting responsibilities. Understanding the reasons that people avoid talking about the illness can help the therapist work with the unique timing and pace issues within each family.
 

Ongoing Crises: Living with Ambiguity

In another family that I am working with, the father, age 50, has fast-advancing ALS. He cannot communicate except with a raise of his eyebrow. Though he has decided not to go on a ventilator, there are many caregivers, involved and the ALS Center continues to try to find ways to relieve his symptoms. His mood vacillates between passive acceptance and depression. He is on antidepressants. His wife is overwhelmed. She is angry that everyone keeps expecting her to do more. She cannot sleep at night. One daughter has begun her first year at college; another daughter is away at a boarding school. We meet together as a family. Each family member has extraordinary pressing needs that seem to conflict with each other. We have a series of conversations in which the grief that is the strongest shared experience is brought into their conversation with each other. With this shared experience, sorting out who needs what, who else might help, becomes clearer, though this is a good example of an ongoing chaos story that has no good ending in sight. Sometimes even taking the time for therapy feels like a burden since there are so many people providing different services.
 

Death and Dying: Letting Go

Sometimes people can make a conscious choice to die, as Ron did in turning off his ventilator. It took many months for him to make this decision. We had conversations with family members, ethicists, psychotherapists and spiritual teachers. Once he decided to turn off the ventilator off, he went through the process of saying goodbye to the important people in his life, even though he could barely speak. More often death is not planned, but sudden, and often a crisis. Inviting families to include conversations about death and dying can be helpful, but often patients resist this fiercely as they hold onto life. Sometimes these conversations work better not all together but separately, with different family members at first and then leading to a wider discussion. When families with adult children come back together as a family often old hurts reappear. These need to be addressed and everyone needs some time to catch up with each other in order to move forward together. Families with younger children have to match conversations about death and dying with the age of each child.
 

After Death: Going Forward

As I said at the beginning, many issues of distress last much longer than people expect. Careful assessment is often needed. Different family members have different responses. When working with children in particular, it is sometimes difficult to sort out what is PTSD and what is grief. If supported in these differences, family members and the family as a whole often mobilizes new resources to transform itself.
 

Summary of Suggested Therapeutic Practices

Diagnosis 
Dilemma: Maintaining the familiar with radical change
  1. Providing a safe container for the expression of intense shock and disbelief.
  2. Facilitating conversations about the diagnosis with children and extended family members.
  3. Bearing with the family the ambiguity of not-knowing the outcome.
  4. Searching for ways to maintain the normal everyday of life, especially for children.
  5. Shifting anxiety about not knowing to finding out information from others.
  6. Discussing ways that other family members and/or friends can participate in the crisis.
  7. Helping families make and/or face medical decisions and prepare questions for meetings with doctors.
  8. Advocating for families in their dialogues with medical and insurance systems.
Ongoing Crises 
Dilemma: Sustaining hope with continuing loss
  1. Normalizing a distorted sense of time and feelings of anxiety and depression as predictable responses to ongoing crises.
  2. Including your experiences with catastrophic illness and death.
  3. Paying attention for and treating overwhelming depression or anxiety in the patient and family members.
  4. Facilitating conversations about the meanings of illness and death in the family and in the wider social context.
  5. Searching out underlying values, beliefs and family history that have led to these meanings.
  6. Looking for stories and practices in the family and in the wider culture that offer other possible meanings and responses to illness and death.
  7. Bearing and talking about the ongoing pain with the patient and the family as they witness the illness worsen.
  8. Finding creative ways for the family to spend good times together within their limited circumstances.
  9. Allowing for the different experiences and needs of the patient and family members.
  10. Facilitating dialogues and planning that take into account these differences.
  11. Convening a wider circle of friends and family to facilitate ongoing support networks.
  12. Bringing nursing, medical, spiritual and social service providers together with the family to assess ongoing needs and to provide coordinated services.
Conscious death and dying 
Dilemma: Knowing the unknowable
  1. Providing openings for conversations about death and dying.
  2. Tolerating and experiencing intense grief with family members.
  3. Exploring beliefs, meanings and family stories about death and dying.
  4. Participating with families in discussions about the economic, ethical, social and spiritual implications of life support systems.
  5. Offering opportunities for friends, family members and spiritual teachers to participate in these conversations.
  6. Discussing desired rituals and practices in preparation for dying and death.

Bibliography

Boss, P. (1999). Ambiguous Loss. Cambridge, Massachusetts: Harvard University
Frank, A. (1998). "Just Listening: Narrative and Deep Illness", Families, Systems & Health. Vol. 18, No. 3.
Hanh, T.N. (1975). The Miracle of Mindfulness. New York: Beacon.
Johnson, F. (1996). Geography of the Heart. New York: Scribner.
Kuhl, D. (2002). What Dying People Want. New York: Public Affairs/Perseus Books.
Langer, L. (1975) The Holocaust. New Haven: Yale University
Levine, S. (1987). Healing into Life and Death. New York: Anchor.
Lewis, C.S (1976). A Grief Observed. New York: Bantam.
Polin, I. (1994). Taking Charge: How to Master Common Fears of Long-Term Illness. New York: Times Books
McDaniel, S. & Campbell, T. (1997). "Training Health Professionals to Collaborate", Families, Systems and Health. Vol 15, No. 4.
Pulleyblank, E. "Hard Lessons." The Family Therapy Networker. January.
Pulleyblank, E. (2000). "Sending Out the Call: Community as a Source of Healing, Families Systems and Health. Vol.17, No.4.
Pulleyblank Coffey (2003). "The Symptom is Stillness: Living with and Dying from ALS, A Progressive Neurological Disease." Chapter in: End of Life Care, Berzoff, J. & Silverman, P (eds.) New York: Columbia University Press (in press). **
Quill, T. (2002). Caring for Patients at the End of Life. New York: Oxford Press.
Rolland, J. (1994). Families, Illness and Disability: An Integrative Treatment Model. New York: Basic Books.
Spiegel, D. (1993). Living Beyond Limits. New York: Fawcett Columbine.
Staton, J., Shuy, R., Byock, I. (2002). A Few Months to Live. Washington D.C.: Georgetown University Press.
 
**Copy of chapter available from author. Contact at: epulleybl@aol.com.

Shades of Gray: When a therapist and her client are survivors of child abuse

Posted on by rezendevknowfully.com

Not a case to wow you with

This story is about humanness, grayness, and uncertainty in practicing psychotherapy. It's not about the times I've wowed a client with my perceptiveness and incisive interpretations. Neither will I focus on times when I've made a clear misstep, like mixing up two clients' stories. This is about intentionally making an imperfect decision to accept a college student as a client who was suffering from the effects of severe childhood sexual and physical abuse, while I at the same time was dealing with my own similar past. In the case I will present, it later became clear that Callie was living with significant dissociation and identity confusion.

My decision to work with her was based partly on the difficulty of finding a better alternative. But I can now say, in retrospect, that underlying this decision was my own difficulty in acknowledging the power of my past and the strength of my defenses. In the end, did I make the right decision? I must admit the results were mixed. Like a swirling mixture of white paint with distinct flecks of black, a picture emerges for me that now, from the distance of time, reads as gray.

I've seen many times over (on both sides of the couch) this insidious grayness seeping into therapeutic relationships. My first therapist took a position that suddenly put him in frequent contact with all my peers in my graduate program—the very people I had been talking to him about. His decisions and handling of the matter brought about multiple problems involving boundaries, trust and our alliance which were painful for me and ultimately interfered in our relationship and the work.

I, too, have found that in my current position, working at a counseling center in a small, rural university, unavoidable boundary questions pop up regularly. “Do I allow a client to join a student project I'm running at the university? Do I attempt to prevent a former client from later working as a graduate assistant at our center?” When I present to a class, will clients be in the audience? I imagine most therapists unwittingly find themselves in uncertain ethical waters from time to time and that guidelines for dealing with such matters offer no off-the-shelf solutions. Instead, they must be worked through taking into account the people involved and the risks and benefits of the available options.

In this article I will examine just one type of ethical dilemma, but one that any therapist with a traumatic past must face: “When are we far enough down the path of our own healing that we can safely go back and help someone else along?” To what extent are we actually in a better position to help our fellow survivors because we can relate to their pain and have a burning desire to help them? Or are we so familiar with the client's pain that it triggers our own pain and the ensuing defenses? Or is it a little of both, and if so, what then?

Tragic life story

Callie1 first became known to me through Ella, an experienced counselor I was supervising during her doctoral internship at our center. Callie was a plucky woman in her early twenties who was referred by one of her professors. His class was working on a project that had sexual abuse as its theme, and the professor sensed from Callie's reaction that it was raising some emotional issues for her. At first, Callie denied any emotional difficulty with the project. But this stoicism proved to be a thin veneer covering a deeply wounded individual. Her life story, as she related it over the course of one and a half years of treatment with Ella and me, was the most tragic I have heard.

Callie was bounced from caretaker to caretaker from the time she was six months old until she was eight years old. At four years old, she was repeatedly sexually abused by her mother's boyfriend, causing permanent damage to her uterus. The perpetrator went to jail. Her mother, who knew about the abuse and didn't prevent it, also abused her both physically and emotionally. Indeed, Callie recalled how on her fifth birthday her mother had taken away an unopened present she had bought for her because Callie had let child protective workers into the house. Callie recalled other punishments, such as being burned with cigarettes and being locked in a room for a week.

One of the most horrific abuses occurred after a teacher told her mother that Callie preferred to write with her left hand, but should be encouraged to use her right hand. “Her mother brought Callie outside and told her to hold her left hand behind the tire of their car while she drove over it, crushing the bones.” Verbal abuse included her mother calling her vulgar names and telling her that she had never wanted Callie, and in fact hated her.

Callie was also abused by another of her mother's boyfriends. Over the years, he broke approximately eight of her bones. Once he dropped her head-first off a balcony. After the injuries, she was driven to far-away hospitals so that no one would suspect abuse.

In therapy with Ella, Callie reported that she experienced recurring depression with occasional suicidal thoughts. She had been cutting herself off and on for about seven years. Significantly, she also stated she felt different than others. This hint at identity problems would prove to be a huge understatement.

Introducing Stacie

Callie let Ella know that she trusted her, and opened up to her about these very painful past and present difficulties. “In her tenth session, Callie arrived in fancier clothes and, to Ella's surprise, referred to herself as "Stacie."” Rather than question it, Ella decided to "go with it." Realizing this as an opportunity to understand a normally hidden part of Callie, Ella asked Stacie questions about herself. Stacie, she said, protects Callie. Stacie saw herself as different from Callie. For instance, Callie didn't like her live-in boyfriend, but Stacie did and worked to keep him around. Stacie showed up again the next session. She stated that she first appeared on the scene when Callie had been sexually abused at age four. In Stacie's mind, Stacie herself was never abused. In fact, she didn't even have the same mother or last name as Callie. Stacie asked Ella not to mention her existence to Callie because Callie would "freak" if she knew about her.

Ella agreed to this request, but disclosed in supervision that she was not sure if this was the right decision or not. We discussed Callie's ultimate need to know about Stacie, but decided not to push the issue at that time. We wanted to give Stacie a chance to express herself without fear of overwhelming Callie.

It was Callie who showed up for the following session. Although she talked of forgetfulness, she didn't see it as a real problem. “If she saw books around her apartment that she didn't recognize, she would simply think to herself, "I must have bought them."”

Ella's internship was coming to an end, and the termination with Callie was not a smooth one. Two months before Ella's departure, Callie called her in crisis. Walking to her off-campus apartment the night before, Callie had been raped by a stranger. For many subsequent weeks, Callie naturally felt terrified, and would sometimes even hide in her closet at night. Although she continued to present herself as Callie during these sessions, during one session she said she felt like a child, and during another she described feeling like she was in a dollhouse with others controlling her. Her depression and cutting behaviors increased, and she hinted at feeling suicidal. Ella spent the last sessions continuing to help Callie cope with the rape, and processing her sadness about friends graduating and their therapeutic relationship ending.

Unspeakable, unthinkable and unknowable

The decision about where Callie should be seen next for therapy was not taken lightly. Ella suggested the possibility that I take her on as my client. This option made sense for several reasons: I had supervised Ella over the previous six months, so I was familiar with the case; Callie did not have transportation, money or insurance, so a workable off-campus referral would have been difficult to arrange; and, with Callie's permission, I would be able to continue consulting with Ella while working with Callie. While a referral to another therapist in our center would normally be a possibility, our center only employs one other psychologist. Callie had expressed fear of the other psychologist because she looks similar to her mother. The reasons for me to see Callie were stacking up, but the idea made me anxious.

This is where my own past enters in. Like Callie, I was sexually abused as a young child on multiple occasions. For me, it was by my father. Here, the "un" words best describe my reaction: The terror was unspeakable. The sinking feeling I felt upon realizing that my own father was capable of hurting me in that way was unthinkable. In fact, the whole experience was unknowable. It was too much to take in, too much to remember. A severing process began taking place in my brain. I now believe I would actually forget the abuse between episodes. But when the circumstances that led to abuse would recur, I would remember. In my child mind I would plan how to keep myself safe. Unfortunately, my army of stuffed toys, oversized nightgown, and tucked-in pajama shirt were surprisingly poor defenses. This thing that was too much to know would happen again. By middle school, I feared I was becoming insane because I spent so much time out of my body and things felt unreal. For instance, I would be engaged with others at school and then suddenly feel as if my connection to both myself (my identity, body and past) and my surroundings had been severed. I felt more like a consciousness than a person. I would try to behave as normally as possible until the episode passed, but it was hard.

Today, I function well. I have come a long way through my own psychotherapy. In fact, it's easy to be lulled into a sense of having made it, having survived and moved on. Occasionally, something will trigger my memories, and my defenses will rush to the rescue, warping my sense of time, place, and self. It's hard to process information at those times, which I suppose is the point of dissociation. But that state is transient and I understand it. That said, I do sometimes wonder if what seems normal to me, like episodes of dissociation, may be more abnormal than I can appreciate.

At first, I declined to take on Callie as a client, but offered to meet with her temporarily while we worked out a more appropriate referral. Soon after termination with Ella, Callie cut herself deeply enough to require hospitalization. She did not remember making the cuts. I realized that, ideally, Callie should receive treatment from an agency that had emergency back-up and a specialist in Dissociative Identity Disorder (DID). I referred her to a crime victim's center in the nearest town that specializes in trauma treatment. However, I was surprised to find that the therapist assigned to Callie was less qualified to take her on than I was. In fact, I learned that no one at the agency had experience working with DID. Although the nearest city had appropriate referrals, it was an hour and a half away.

Soon after her release from the hospital, Callie cut herself again, and was again hospitalized. Like the last time, she did not remember making the cuts. As the only therapist currently connected with her, and with an obligation to manage our students' mental health crises, I continued seeing her for crisis management.

Entering the grayness

Over these sessions, I started gaining confidence in my ability to meet with Callie. I felt like my interventions were helpful. I revisited the idea of taking her on myself. I considered the facts: By default and necessity, I had already established a therapeutic alliance with Callie; I had an understanding of her past and current difficulties; I was knowledgeable about the psychological effects of childhood trauma; and I wanted to help her. I decided to take the plunge. I offered Callie regular psychotherapy sessions and she agreed. I looked into the possibility of consulting with a DID specialist for supervision over the phone and was able to set this up. I assured myself that if I ran into personal problems doing this work, I would process them with this DID supervisor or with my informal peer supervision group. I would like to announce that I opened up and worked through my past fully in this case, but in reality, I never found the courage to do this. Although I discussed my work with Callie, along with my less-private reactions toward her, I avoided anything that had to do with my own abuse. The anxiety that would get triggered when I contemplated bringing up my past felt insurmountable.

Callie was open and disclosing with me but also seemed a bit distant. I wondered if she was reacting to my own sense of uneasiness. I was aware of an internal sensation of steeling myself when she talked. I wanted to be receptive to her, but I could feel that I was also being self-protective. I was slightly unnatural with Callie, always trying to work against my instincts to defend myself.

Nonetheless, we were making progress. “At the suggestion of my supervisor, I began to talk to Callie about her alters.” She was resistant, so I proceeded cautiously. She admitted that her boyfriend would tell her that she was other people sometimes. He told her that she would occasionally drink from a baby bottle. When he would report on her strange behaviors, she would cover her ears and start humming. She also disclosed that she stopped reading her journal because she would read things she didn't remember writing, such as entries about her mother, but from a younger perspective. At times, she would get fuzzy in session and dissociate. She would say that she did not feel she was fully in her body. We would stop and do grounding work.

One evening I received a crisis call from Callie. Her boyfriend told her she had just pulled a knife on him in a threatening manner. Despite her objections, I called an ambulance to pick her up so she could be evaluated at a hospital. She did not remember this incident either, and I suspected involvement of the alters. In fact, there was accumulating evidence that the alters were "out" quite a bit of the time.
 


A gift to the therapist from Stacie upon termination of therapy.
This painting depicts Callie and the alters in front of the house in which they live.

A turning point in our sessions came when, again at the suggestion of my supervisor, I asked Callie, "Is there a Stacie there?" She paused. She said that she would find things with the name Stacie around her apartment. Also, her foster mother had given her a red-haired doll named Stacy, and she had always liked that name. I explained she had presented herself as Stacie to Ella.

The next session, Callie showed up looking differently. She wore make-up, fancier clothes and smiled a lot. I asked if she was Callie. She said, "No, I'm Stacie." For the rest of the school year, until Callie graduated, I would see Stacie often. Stacie knew all about the others.

“In all, Stacie told me about all 11 different parts or alters, including herself and Callie, ranging in age from 4 to 22” (Callie's age). In Stacie's mind, they all lived in a house where they each had their own room. In addition to Stacie, I also saw the four-year-old, Tracy, who missed her "mother" (actually, Callie's elderly relative who took care of her for several years). Jenna, who was sad, angry, and wanted to die, presented herself as well. Jenna called one day to tell me that her ribs hurt and she didn't understand why no one would take her to the hospital.

By the time of graduation, evidence of improvement came when Stacie started whispering things to Callie. Callie was apprehensive, but also intrigued at the prospect of getting in touch with another part of herself.

The silver lining

As we came to the end of the school year and were facing termination due to Callie's graduation, we talked about our relationship. She told me that she liked me and that I was one of only five people she trusted. However, she also disclosed her initial reactions to me that confirmed some of my fears. “She said that in our early sessions she felt I didn't like her because I tend to sit back in my chair and talk in the lower range of my natural voice.” She initially reacted to this, she said, by not liking me either, so she wouldn't get hurt. Also, she said that she did not find me as warm and open as Ella. However, she reported that her feelings changed over time and she grew to like and trust me. Because this feedback was different than any of the feedback I've received over the years, I assume that I was, indeed, somehow different with Callie.

Those words were hard to hear, but they also gave me a great opportunity. Callie had some borderline tendencies, and not surprisingly, in her relationships with others, she tended to split. I pointed out that she seemed to put people into two camps: perfect people who she saw as her saviors, and others who she viewed as "all bad." She immediately accepted this observation, and added that saviors who fail her fall right down into the "all bad" category. I told her that I hoped that our relationship helped her to see that there's actually gray in the world. I had my imperfections, but she had found that she could still like me, trust me, and connect to me overall.

And so, out of the gray imperfect mismatching of a wounded therapist with a wounded client, came a lesson that I hope has staying power for Callie. Sometimes gray is what we get, and sometimes gray is enough.

I will never know if I made the right decision in accepting Callie as a client. Healing from early trauma is a process with no definite end point. I do know that the timing was not ideal. I had not fully appreciated the power of my past, and was too ashamed and avoidant to seek out more intensive supervision when I suspected it was interfering. Indeed, based on my experience in working with Callie, I have become even more convinced of the value for therapists who are survivors to explore their past in supervision when working with client survivors. When ready to do this, I believe he or she will be in a more powerful position to help his or her fellow survivors.

Perhaps most therapists are never fully trained or completely ready to work with such overwhelming stories of child abuse, but certainly getting extra support for myself would have eased the burden. Perhaps if I had disclosed to my supervisor my concerns about taking on Callie due to my own past, she could have helped me talk through the pros and cons and we could have made a decision together. If we decided that I should go ahead and work with Callie, which I suspect would have been the case, I would have felt supported and therefore more confident in my decision. I believe this would have made me more confident in sessions with Callie.

Mostly though, I simply needed to express to someone the emotional hurt I felt—for the both of us—when Callie talked about the abuse and her longing for a loving parent. Her therapy was emotionally difficult for me, as well as for her. With more support, I believe I could have been less self-protective and more open to her pain.

It's been a year since Callie graduated from college. She has contacted me sporadically over the course of the year. After graduating, she moved away to live and work in the post-academic world—a heroic but ultimately shaky endeavor. She had searched for a therapist in her new city, but no one would take her on due to liability concerns. At her new job, coworkers began telling her that she seemed like different people at different times. Her thoughts turned to suicide. She moved back to her college town and was taken in by a middle-aged couple who had helped her through her college years.

By coincidence, after not hearing from Callie in months, I ran into Stacie last week. Smiling and radiant, she gave me a big hug. Her hair color had changed since I last saw her; she had added a reddish hue. She said she had dyed it on impulse the night before. I thought of her beloved Stacy doll. I wondered what Callie would think of it.

Thunderclouds, weapons and armor

Gray is the color of thunderclouds, weapons, and armor. We often use the word gray to describe situations of uncertainty. A blending of black and white, it represents a mixture of good and bad, right and wrong, danger and safety. It's harder to take a stand on gray areas. It's often not clear if we should turn back or soldier on. Ironically, gray is also a red flag. It warns us that if we decide to soldier on, we must go forward with humility and support, things which could have helped me to face myself more fully as a person and as a therapist. Whereas the basic supervision and consultation I received was quite invaluable, I was often left adrift and rudderless without the support and resources that I wish I would have engaged.

Just as Callie struggled to understand the gray areas in life, so did I. Gray is not something we choose, but so often something we get anyway. Gray was what I gave to Callie. I hope it was enough.

In such moments of hope paired with self-doubt, I remind myself what I told Callie: Sometimes we must accept a level of disappointment in order to take in the positives. We are called to accept our limitations, and do what we can do, even with the messiness and inherent contradictions life offers us. On one hand, my own childhood trauma offered me a way to understand and connect to Callie and her house full of alters; on the other, it kept me from being fully present with myself and Callie.

“Grayness is real, so running from it does little for those like Callie or for our own growth as therapists and human beings.” Perhaps in the meeting of my grayness with hers, some meaningful realness was forged that can sustain her in the roughest of times. Remembering that gray truth helps to sustain me, as well.

Notes

1 Names are changed to pseudonyms throughout the article, including the author.

9/11 One Year Later: A Psychotherapist Reflects on His Experiences at Ground Zero

Posted on by Psychotherapy.net Team
As we pass the one year anniversary of the terrorist attacks of September 11, 2001, Americans are reflecting on the toll this event has taken on our collective consciousness. Due in large part to the power of the media to magnify this spectacle to epic proportions, it is arguably the most traumatizing event in post-modern times. As mental health professionals, we can witness the reverberations of 9/11 from a unique vantage point. Although clients in my private practice have rarely cited the terrorist attacks as a presenting problem, there was clearly a great deal of thought and energy devoted to reassessing priorities and choices. In the first month following the attacks, it was impossible for me to conduct a psychotherapy session without acknowledging the tragedy. My clients and I had a rare opportunity to share moments of mutual empathy that deviated from the usual limits of the therapeutic relationship.
 
Despite this, my professional activities felt inadequate in addressing my own need to do something more in response to 9/11. When a colleague told me of her positive experience as a Red Cross disaster mental health volunteer, and the need for assistance with the relief effort in New York City, I felt drawn, compelled, to join. After completing the orientation and training classes provided by the Red Cross, I found myself reconnecting with the idealism and passion that first attracted me to human service.
 

Arriving in Manhattan

I arrived in New York on 12/19/01 ready to do my part. I completed the necessary in-processing at headquarters and took a cab to the hotel room provided by the Red Cross in midtown Manhattan. Negotiating subways, cabs, and crosswalks was challenging at first, but I was soon able to pick up a bagel and coffee and make it to the downtown A-train without being late to my destination.
 
Getting to know the city firsthand helped me appreciate the changes that had occurred since 9/11. I was told that in the aftermath of the disaster, New Yorkers became more open than usual, with some people actually talking to strangers on the subway. Those I encountered were genuinely appreciative of the volunteers from out of town, expressing an uncharacteristic sense of their vulnerability, and need for assistance. The 9/11 attacks made us all painfully aware of the limits of our technological infrastructure, and the fragility of our human bonds.
 
I was assigned to a huge tent next to the 16-acre pit at Ground Zero, which served as a respite center for the firefighters, police officers, and other workers. This site was staffed round the clock, and I worked the 4pm to midnight shift in the dining area where the recovery workers took their breaks. Our duties at Ground Zero consisted of circulating around the tent, striking up conversations, and offering support and information. Interactions with the workers ran the gamut, from chitchat about upcoming football games, to personal discussions of the search for missing friends. About half of the contacts were interested in talking about the recovery work, but far fewer were willing and able to express feelings about the disaster.
 

How Ground Zero Stretched the Therapeutic Role

It became clear early on that the workers were making a great effort to suppress their emotions in order to carry out their difficult tasks. Almost all of the workers had lost at least one friend or colleague in the World Trade Center. In this intensely chaotic yet controlled environment, the appropriate role of mental health volunteers was to engage Ground Zero workers in a delicate dance between small talk and existential validation. It felt as if we were there primarily to bear witness to the experiences of the Ground Zero workers, as they endured 12-hour shifts recovering human remains, struggling to keep their exhaustion and grief from interfering with the mission.
 
Balancing this unconventional therapeutic role, alternating between schmoozing and debriefing, proved to be terribly fatiguing at first. It was a stretch from the more evocative style of my mental health practice. At times, I felt as if I was carrying the unexpressed grief of the recovery workers back to my hotel room every night as I searched myself for the empathic response to their ordeal. Processing my experiences on a daily basis with other disaster mental health volunteers rewarded me with the awareness that our mere presence at Ground Zero was our greatest contribution to the workers there. “We weren't expected to have any words of wisdom… and nobody did.”
 
Some of my disaster mental health colleagues in New York worked with family members of victims who were openly grieving and verbalizing their experiences. My assignment at Ground Zero was quite the opposite; in fact, it may have been the location in Manhattan where one was least likely to witness the venting of feelings.
 

Herculean Efforts and Unexpressed Sorrow

Being present in this hallowed ground, with the sound of heavy equipment, and the smell of combustion and decomposition ever present, was a trying task for everyone there. The Herculean effort of the recovery workers, to postpone their natural emotional response, was both impressive and poignant. A group of firefighters sat at a table, laughing and joking about some trivial issue, after hours of raking through the piles of debris in search of missing colleagues. One police officer, who led his cadaver dog into the pit to assist in the locating of bodies, told me of the difficulty of suppressing the horrible images he encountered when he returned home to his wife and children. A fire captain solemnly acknowledged to me that, even after three months, the recovery workers were driven by the desperate hope that, somewhere in the six-acre pit, a living soul was waiting to be rescued.
 
Among the recovery workers there was a continuum of emotional expressiveness which appeared inversely proportional to the individual's proximity to the disaster. That is, the closer the worker was to Ground Zero, the less emotional expression was evident. In general, the firefighters were the most guarded and difficult to approach. I am not sure why, but they did suffer the largest overall loss in their ranks (close to 10%). The various police officers were more receptive to interactions with the disaster mental health workers. Perhaps the most approachable and, ironically, underserved group of workers at Ground Zero were the ironworkers, welders, heavy equipment operators, drivers, engineers, and other construction workers who were contracted to clear the site. Unlike the police and firefighters, these workers had no professional preparation for working around human remains. Add to this the reality that many of these men and women had worked nearly every day since 9/11, without break either by their own choice, or by virtue of the critical nature of their skills, and it is becomes clear that they represent a segment of victims of the WTC disaster that warrant closer attention.
 
I had never felt such a heaviness of unexpressed sorrow, though it resonated deeply with my own personal family losses prior to 9/11. My evocative skills were not useful at Ground Zero… I felt burdened, at times, with the violence and trauma that was ever-present yet still mostly unprocessed. Over my two weeks in lower Manhattan, my PTSD response took the form of sleeplessness and fatigue. Yet, too, I was surprised at the absence of nightmares that I had expected would occur. Perhaps the daytime witnessing of horrors made such nightmares superfluous.
 

Leaving Manhattan… Returning Home

The practical function of the disaster mental health professional at Ground Zero was as a vessel, or conduit of pain to facilitate the recovery work; I knew that I would have to carry my share of it home with me.
 
The Red Cross cautioned the volunteers that when we returned home people would ask about our experiences. They suggested that we would find it difficult or impossible to convey our true feelings and experiences to those who had not been there. That was indeed an understatement! Even here, in writing this account, do I find it so hard, so inexplicably difficult to express my experiences fully.
 
As the days and weeks passed, I felt more and more as if I had walked away from a battleground—with all the grief, psychic numbing, and survivor guilt that goes with such trauma. Indeed, I had walked away from a battleground—it was not "just a feeling." I had crossed the line between observer and participant, and no professional objectivity would suffice. My mental health colleagues and anyone else who ventured close to the unprecedented injury and destruction of the 9/11 attacks knows of what I speak. “This ineffable experience is captured best, not in any words, no matter how well expressed, but in the silent glances between workers, the hugs of those that care, the hope of those who courageously carry on in spite of loss and despair.”
 
Despite the routine debriefings provided by the Red Cross, I left New York with more than a lifetime's worth of intense images and sensations. I intuitively knew that my disaster mental health experience would be life-changing, but I did not know exactly how.
 
At first my clinical practice felt boring in contrast to what I had witnessed in New York.I felt different, as if I had expanded, or gained access to parts of my own life that I had not seen before. At first my clinical practice felt boring in contrast to what I had witnessed in New York. I found myself reaching to find the relevance in the complaints of the worried well, which suddenly felt terribly trivial. My style shifted, temporarily, to a less patient, more emphatic "let's get on with it" tempo. I soon became aware that I was unwittingly projecting my need for catharsis onto my clients. This awareness was the first step in beginning to understand what all this meant to me. I too, needed to know and understand my feelings, to express and share my fears and sorrows, and take the risk at experiencing catharsis in my own life.
 
Opportunities to share my disaster mental health experience, both publicly and privately, have given perspective to my images of Ground Zero, and grounding to my emotions. I feel more vitally connected to my soul and less attached to old assumptions. My work has settled into a serenely energized stance. Now, when I am sitting with my clients, I feel that we are more in touch with each other's humanity than before-or rather, more than I had previously allowed.
 
At Ground Zero, my instincts were all I had to work with; they have since become my most valuable therapeutic resource.

Edna Foa on Prolonged Exposure Therapy

Posted on by rezendevknowfully.com

Exposure Therapy Explained

Keith Sutton: Welcome, Dr. Foa. To get started, why don’t you tell us a little bit about what exposure therapy is. Many of our readers may be unfamiliar with, or may not remember much about, this type of therapy.
Edna Foa: Exposure therapy is used mostly with anxiety disorder. The idea is that people who suffer from anxiety disorders—who get anxious when they confront safe situations or objects—are taught through exposure therapy to become less afraid, or not afraid at all, of the things they’re fearful of. So if the fear is a normal fear—like the fear of driving on the track when you see the train whipping by very fast—you don’t want to teach people to get over it. You don’t want to change people’s fear of driving over the track just in front of the train, because normal fears protect people from doing things that will harm them. The idea behind exposure therapy is that the therapist helps patients to confront or approach what they’re afraid of, because the things they’re afraid of are intrinsically not dangerous. Through exposure to these situations, they learn that there is no reason to be afraid of these situations. The disaster they expected does not occur. Originally, exposure therapy was derived from animal studies. In these experiments, scientists condition a mouse to become afraid of a red light by pairing the light with electrical shock. And after a certain numbers of pairings, the mouse will start showing fear responses when the red light is presented, even when it’s not paired anymore with shock. We call this response a conditioned fear. Then if we want to eliminate the mouse’s fear of red light, we present it with a red light without the shock. After repeated presentation of the light without shock, the animal stops showing the fear reaction to the light. That’s called extinction. In the ’60s and the ’70s, several experts, in England and the United States, translated the animal results to human beings and said, "Let’s suppose that the anxiety disorders—such as claustrophobia or fear of heights—are like a response that was conditioned. The person was conditioned to be afraid of elevators even though being in an elevator is not dangerous. So how do we eliminate the fear of elevators? We instruct the person to ride on an elevator many times until the fear is extinguished."

KS: Is that what’s called the flooding of the anxiety?
EF: Well, it’s called flooding if the therapist conducts the exposure very abruptly. And it’s called systematic desensitization if the therapist is doing the exposure very slowly in small increments, and if he pairs the exposure with relaxation. There were big debates in the '60s and the '70s about what works better, and whether flooding is dangerous. Some experts, like Wolpe, thought it was dangerous to do flooding because the person will actually become more rather than less fearful.
KS: Yeah, common sense would make you think that, wouldn’t it?
EF: No, not really. According to some theories, flooding should make the patient feel worse. But according to other theories, abrupt exposure should extinguish the patient’s fear more quickly, so it is actually more efficient.
KS: One of the central ideas around the exposure is that the anxiety peaks within a reasonable amount of time and decreases. Is that right?
EF: Well, it depends. Not necessarily. Let’s say that somebody is afraid of going to the supermarket. People with panic disorder, you know, are afraid of going to places where they cannot escape quickly, like sitting in the first row at the movies. It takes longer to get out from the first row than from last row. Experts did abrupt exposure, getting patients to sit in the front seat from the start of the therapy, and other experts said, "Let’s do it incrementally—let them sit in the last row first, and then in the row before the last, and then two rows before the last, and then five rows before the last."
KS: Is that the exposure hierarchy?
EF: Exactly. Gradual exposure gets patients used to each one of those stages, and eventually the patient will sit in the first row. Now, studies have found that doing abrupt exposure is as effective as doing gradual exposure, except that the patients in the gradual exposure suffer less. But flooding doesn’t really make them worse, as Wolpe thought. So we know now that we can do flooding, or we can do systematic desensitization. Both work. Today, experts don’t quarrel about this issue anymore; all therapists use more or less a gradual exposure, but not as gradual as systematic desensitization, because that takes too long and is unnecessary.So that’s what exposure is. Now, how does exposure work? It works because of a mechanism that we call extinction. Extinction is not unlearning what you learned, but rather it’s learning something new—it’s learning that what you were afraid of is not dangerous. Some experts say that the mechanism is the reduction of the anxiety—that gradually you’re less and less fearful. This is called habituation. But habituation is not an explanation for why patients get less fearful with exposure therapy.My theory is that exposure reduces fear and anxiety because the patient learns that the bad thing he thought would happen to him does not happen. Therefore, it’s very important to plan in a way which will ensure that the thing the patient is afraid of will not happen during the exposure. Let’s say after being raped a woman starts to be afraid of going anywhere by herself after dark. The therapist then plans exposures to places that are not safe after dark, and she is attacked again. That’s not a good exposure, because it doesn’t teach the patient that what she was afraid of does not happen.I always give the example of a person that is afraid of big dogs, but not of small dogs. The therapist decides to treat him by exposure to dogs, and brings to the session a small dog. Well, because the patient is not afraid of small dogs, this exposure will not work. Exposure needs to include the things that the patient is afraid of. The therapist then brings a big dog to the therapy session to do exposure. The patient enters the room, sees the dog, and gets very fearful. With the encouragement of the therapist, the patient slowly approaches the dog, which the therapist holds on a leash. When the patient gets close to the dog, the dog jumps on him and bites him. This is again not a successful exposure, because what does the person learn from it? He learns that he was right all along, that big dogs are dangerous.
KS: It reinforces that belief.
EF: Exactly, it reinforces rather than extinguishes the fear. So that’s the way exposure works. In order to implement therapeutic exposure, the therapist has to find out what the person is afraid of, then make a list of these things and organize this list from the not-so-fearful situation to most fearful situation, in a kind of hierarchy. In order to create a good hierarchy, the therapist teaches the patient to assign a number, on a zero-to-one-hundred scale, to each situation. This number signifies how much fear the patient would have if he would be confronted with this situation. It is important that the therapist makes sure that the situations on the list are not really dangerous.The therapist chooses a situation by saying to the patient, "Let’s choose a situation that is about forty on the scale. Which of these situations do you think you are able to do for homework next week or in the session with me?" The patient selects a situation and begins to practice approaching it, staying in the situation until he feels that the anxiety goes down and realizes that the fear is not realistic.So exposure works through two mechanisms. The first is that the situation elicits the patient’s fear—there is a match between the situation that the therapist is presenting to the patient and the patient’s own internal fear. The second mechanism is that the exposure situation contains information that is incompatible with the information that the patient has in his mind. In the example I gave you about the dog-phobic, if the patient is afraid that large dogs will bite him and the therapist presents him with a large dog that, over several instances, does not bite, the patient will cease to be afraid of big dogs. Patients don’t really need to be in the situation a long time—they don’t need to wait until the anxiety dissipates completely. They just need to be in the situation long enough to realize that what they feared would happen does not happen.

Transforming the Wounds of Racism: An Autoethnographic Exploration and Implications for Psychotherapy

Posted on by rezendevknowfully.com

A young boy splatters my painstakingly finished painting, taunting me to go back to where I had come from. I accuse his ancestors of plundering my nation: "Look what your people have done to my people." (Saira, eight years old)

The stories of colonialism that my father had told me suddenly came to life and I felt bold and proud as I looked to my teacher for further confirmation. She remained silent as the other children laughed at me. I found myself shrinking away in that moment of humiliation. I think about that experience quite often and I imagine what might have happened if my teacher had affirmed my words. Especially, now that the cultural landscape has changed and I see white women with henna tattoos, and Indian fashions, designs and music everywhere I look. It is curious that what was once denigrated is now accepted and desired. This is both inexplicable and inspiring to me.

My brother and I are in the garden gathering brittle autumn leaves for the fire, savouring the sweet evening air in our lungs. Two white teenage boys peer over our back fence and throw stones and litter at us alongside racist jibes. I feel they are treating us like animals in a zoo; I feel fear rise in my belly but feel compelled not to show it. My father appears and gently asks them if they would like to join us. I feel bewildered and betrayed by his reaction. The boys sit beside us and floating embers settle in our hair as we eat baked potatoes plucked from the fire. We make reluctant and inquisitive eye contact with one another and as the fear dissipates, I can see they want to be a part of this simple activity of togetherness. (Saira, ten years old)

Racism was a part of the backdrop of our lives. It was not discussed and I was given no guidance on how to make sense of it. It is only now, many years later, that I recognise the gift my father gave me that night: he showed me that I could acknowledge and stay with the disquiet and dread of racism and that I could find ways other than fear and dread to be with it. During my dissertation research on this topic, I held onto these memories like a talisman.

Authoenthnography as a way to understand racism and trauma

I wanted to become a therapist who was not bound up in the rigidity of her boundaries, so that I could begin to stretch and push the boundaries of otherness and sameness. As a psychotherapist, I wondered how racism is explored or avoided in psychotherapeutic work. I saw that racism can often enter psychotherapy in a disguised form as it is difficult to express due to the fearful and defended nature of racism. This results in racist trauma being overlooked and minimised, which can be oppressive and silencing in itself. In this work, I have tried to illustrate how stories were told and understood in order to facilitate empathy with groups that are sometimes neglected and marginalized.

Autoethnography¹ has developed from ethnography, anthropology, sociology, and cultural studies and serves to challenge traditional historical relations of power. Autoethnography is different from autobiography in that it describes the conflict of culture and identifies how one becomes othered within a cultural and social context. This method of research allows us to remake and understand subjective experience from creative and analytic first-person accounts of people's lives. It makes use of interviews, dialogues, self-conscious writing, and other creative forms to facilitate an expanded awareness for the author and audience. Autoethnography is the study of the awareness of the self (auto) within culture (ethnic); it is a way to connect the personal with the cultural.

I have tried to create a more heartfelt space where wounds can be subjectively named and understood. I wished to engage in new ways of thinking about how therapists' life events can change practice and awareness for themselves and the field. The illuminated relationship between the researcher and the researched is made transparent in this work as it took me to places, internally and geographically, that I had never been…

This is not just a story about racist trauma—it is a story about longing, loss, and discovery. It weaves back and forth in time, and as a result, it is written in both the present and past tense.

Straddling two worlds

As a child, I was a keen observer, soaking up the living memories of my parents' homeland, of dance, song, and food that produced solidarity and unity. As a group, they felt alienated and displaced from all that was familiar. My aunts told and retold stories; this helped them maintain their cultural voices, and this collectively made them a powerful force in my life. The men were on the edges of these stories and were largely uninvited to storytelling as it was felt they were both "too important" to be burdened with the tales and too "weak" to bear the sorrow associated with them.

I straddled both the ancestral and modern worlds, and I was given the gift of being able to find myself within these stories. Despite the fact that these mementoes of my heritage were somewhat fragmentary, I was still left fascinated by them. My aunts came from a culture that emphasised togetherness and unity. In their dependent and highly emotional world, they sought kinship and solace with each other. This was in part because they became increasingly ambivalent about their splintered place and identity in the world due to the forces of migration.

As I grew older, I started to embody a western culture, and it became apparent that cultural differences were intolerable to my family, as any individuation was an annihilation of the collective. I felt increasingly like an outsider, both inside and outside the home. I was inexplicable and perplexing to them, particularly when at 13, I dyed my hair pink and daubed hand-painted feminist slogans over my clothes. My family clucked with pride when I responded to their coaxing by wearing a sari for a family event. I felt such sensual pleasure in the swaths of beautiful pea-green silk that I did not want to lose its "magical qualities." In turn, [I refused to take the sari off, ruining their hopes by experimentally skateboarding in it.] I was continually challenging their ideas of what a traditional Asian woman should represent and grappling with the contradictions and paradoxes inherent in this process.

Myself as witness

How do I trace the roots of my estrangement and disconnection from these men who were central to my life, to my heart? I have waited for a long time for them to come home—psychically, physically, and emotionally. I have always wished that they would be returned to me, like at the end of fairy tales. Through my research process, I felt like I was making the decision that I could not passively wait for their return any longer. Whilst being immersed in this research, I felt a strong need to reclaim my deeply yearned for yet seemingly irrecoverable lost connections.

I did not know for certain when I started this research that my father, uncle, and brother were lost to me by racism and its effects. These experiences were unheard and unspoken in my rambling and rather tribal family. I believe the speaking of racism evoked fear and shame that might further tear at the fraying fabric of my family. Racism, for me, was bound in the wrappings of humiliation and silence. It was so tightly swathed, I only heard it as a fearful whisper. I have subsequently discovered these traumatic racist experiences ranged from vague, insidious and intangible experiences to shattering, violent acts.

As I felt the oscillations of these unspoken narratives inside myself, it led me to create musings, fantasies and assumptions about the subject matter. I sat at my desk, feeling bewildered and paralyzed at the horror and pain of the family narratives, and despair at their disconnection from me, wondering how it was possible to get closer to the subjectivity of such experience. This possibility felt charged, potent and unfathomable. I deliberated and wondered repeatedly if I should speak with my family about the research—would it harm them further? What are the ethics of taking this into the public world? What would the research do to our relationship? Issues around confidentiality buzzed around my head and my colleagues and I talked about them incessantly.

I questioned the possibility further: What will my peers make of me? Would I be derided and discounted by the "therapeutic community" for revealing not just myself, but also my family? Would I be able to produce something evocative, powerful, and representative of our experiences? Is this the story of significant men in my family or my story of loss? Can I find the words for trauma that sits beyond language to describe what cannot be spoken? The question remained with no easy answers.

My father's scars

My father was disillusioned and troubled when he fled to England to practice law in the 1940s. His best friend and neighbour during the partition in India stabbed him. He only mentioned the scar on his stomach in passing when I pressed him to let me into his interior world. He believed Britishness embodied fairness and justice as he had been successfully inculcated into the colonial belief that he and his kind were inferior. He beamed with pride at redefining himself as a "brown English man" and negated his "primitive and corrupt" cultural origins with vitriol, never wishing to return.

In remaking his identity, he resolutely refused to believe that his struggle to secure a job as a barrister was due even in part to his colour. He was a dishwasher, a porter, and a lift attendant—all the while, trying to maintain his respectability and pride. He would arrive to work with his bowler hat and impeccable pinstriped suit each day. then change into his overalls to start his shift. He was inaccessible to us as he strove to carve out a place in the world, and his identity was embedded in his need to work hard and achieve. His failure critically punctured his self-esteem.

The eventual disaffection and disillusionment with his idealization of Britishness seemed inevitable. However, its impact was made worse because he was unable to digest the racism he endured. He saw the hostile, racist persecutory world making him feel small and powerless. He seemed to see racism and oppression everywhere. These crises led him to alcoholism and admission to a psychiatric hospital for depression.  “He sat on his prayer mat and cried like a child as he spoke of England like a lover that had abandoned and disappointed him.” He turned away from it as he had his homeland.

In turning away from Britishness and all it represented, my father turned further away from me. Had I come to embody what he could not bear? I could not find any comfort in taking my distress to him and he could not bear the weight of his child's woundedness. The effects of his trauma marked our family, and although we did not live through his trauma, we did live within its confines.

It is frustrating to feel the familiar inaccessibility in his death as I did in his life. What would he have discounted or embraced in these descriptions? My father was a harsh man who shielded himself from the world and eventually lived a hermit-like existence, but he gave me the best of his capacity to love. All I can name is what I know: that every day I spent with him he was unpredictable and closed off, living in a desolate land. I could not find him anywhere. And now I cannot quite find him in the untranslatability of these narrative descriptions.

While my own father was busily being a perfectionistic workaholic, my mother was whimsical, dreamy, furiously caught up in her culture and clan. My uncle represented a world of calm and safety. How do I adequately describe how much I loved my uncle? I have always found great comfort in looking at his face, the familiarity I felt in watching him smoking his cigarettes—his recognizable outline meant that my life slotted into place.

My uncle leaves… the unanswered questions

I now realize he was a mere young man at the time, but seemed then to offer a very different quality of attachment. I remember him driving a maroon Mini with a squeaky leather interior that I would slide around on. He would sit with me on the stairs when I had undigested bad dreams about cowboys and Native American Indians and would speak softly of worlds full of magic and kindness until I felt safe enough to fall asleep again. He taught me to gently put the needle on the record and wait breathlessly until the song would start in the smoky recesses of his room. He would capture my crinkle-nosed smile in his photographs and I felt rewarded with his attention and gaze.

His leaving to emigrate to Canada when I was six felt like an unanswered question and for a long time I wondered why he left, and yearned for him to come back. His absence was profoundly painful to me as a child. I wondered if my mother had sent him away or if his new wife asked him to leave. As I grew up, a part of me imagined it was due to racism. Not that I knew much of his experiences with racism, but I overheard fragments of conversations of how he "hated England," and that "terrible things happened to him." It led me to conclude that racism was the only conceivable reason he left. Why did I assume it was racism? Had I made something up? Perhaps it helped me believe as a young child that something terrible took him away rather than facing the fact that he had chosen to leave me.

"It felt embarrassing to talk about the humiliating aspect of it, your sense of masculinity is wounded and injured, you feel that you should have taken a stand but you did not feel able to as a man." (Saira's uncle)

Early on, I asked my uncle what he thought about my research—was it meaningful to him? He said he had many stories of racism and its associated trauma that he had not spoken of, yet they were still alive inside of him. I instantly felt relieved that these experiences were real and not entirely the result of my imagination, although I feared I would not be able to hear and bear these stories. How might the telling of these narratives benefit him? At this stage, I felt lost in the littering of these broken attachments and in a turbulent state of anxiety and confusion, although later I recognised that this was a place of important struggle and sorrow.

Unwelcome in the new world

My uncle arrived in England from Pakistan in the 1950s at 10 years of age accompanied by a throng of older and younger sisters with kilos of sweating Indian sweets wrapped painstakingly in silver foil. However, the family was ill-prepared for the cold as they arrived in the dead of winter in only their thin cotton shirts. All 10 children started their life in Britain in an asbestos-ridden caravan, confused and unsettled after coming from a place of wealth and comfort. Later, the family moved into one room with little space, and their material conditions worsened. They lacked any comprehension of the new culture or landscape they faced. This migratory journey remained an untold story because it evoked shame of their struggle to find a place of belonging and the emotional and literal poverty of their experience. The exodus was supposed to be rich with offers of new possibilities, the enticement laced with the promise that they would be rewarded if they worked hard and managed to forget the familiar sun, and the textures and colours of home.

My uncle was pleased to find that people were initially curious about him, his history, and difference. Later, this changed and it seems humiliation and shame coloured much of his experience as a young man. He remembers standing at a bus stop racially abused whilst those in the polite orderly English queue silently looked on, witnessing him being scorned and disrespected for simply existing. He felt the disdain when he was spat at for embodying and personifying otherness, his palpable foreignness and physicality making him a threat to himself. The skin he represented made him exquisitely visible and invisible.

"Look what the cat's dragged in" was his greeting on the first day at his new job; he was 16. He felt cheated; where was the promise of a better life? Then he was threatened with a knife in a public bathroom where a gang of men in a savage racist attack set upon him, dousing him in their anger and fury. He felt unwelcome in the new world.

He walked around in shame and isolation, wondering how he could make a mark on the world when his voice had fallen away. Humiliation tearing at his throat, he swallowed the contempt and its effects began to house themselves inside of him.

Connection and disconnection

My brother on my Uncle's shoulder, me in the park… I chew on the long feathery grasses that sway in the wind, shimmer in the sunlight; I thought I was eating the sunshine. (Saira as a young child)

These are the happiest times I can remember. I felt connected to the world and myself when I was with my uncle. My adoring view of him was in part due to the way he invited us into other worlds of music, song, and nature. I was full in the stillness.

He and the white English woman that he loved and hoped to marry sat together in the ordinary familiarity of the train carriage. He loved train journeys, watching familiar landmarks appearing and disappearing from view as the train juddered out of the station. This defining journey turned bad for him as a heavily built white man sitting across from him began to mumble and then roar at how "his kind" had defiled his partner's virginity, taking something from him—from all white men. “The pain of past racist violent blows he had experienced did not compare in their intensity to this expression of violent hate that was coming at him now.” The torrid racist expletives bounced around the walls of the carriage, exposing and belittling him.

The emotional impact was initially shock; he described feeling a numbing paralysis in his body. As they decided to escape and disembark at the next station, he wondered how his body would support him, when it felt so insubstantial. Time slowed to a stop as he felt the flush of disgrace and helplessness overcome him. The other travellers in the carriage looked on, some with interest, others with avoidance; did they find themselves agreeing with this man's hate? Is that why they did not protest? Or was it fear that this contempt would be directed towards them?

He felt his girlfriend was defiled in her association with him; it was as if she was contaminated by the colour of his skin into something more sexualised and objectifiable. They never spoke of this incident, but it was the beginning of the end of their relationship, because in that long moment, amongst all of the shame and emasculation, was her witness of his diminishment.

When he moved to Canada, he left me too, but more poignantly he left himself. The racism that had infused his world disconnected him from himself and those around him, such an unspoken cruelty when contact and connection was the gift he gave me.

"Racism was not the main reason I left"

I journeyed to Canada to meet my uncle, 30 years after he left England. To engage in a dialogue about something so personal and painful leaves me anxious and curious. I am researcher/niece/ psychologist/ therapist/child all at the same time. These multiple selves offer a dynamic shifting of one into the other, each adding a new voice. He is a stranger to me now, but there is a strong memory of childhood intimacy that attracts me to him. Yet I feel shy. I want to hide away in my researcher/therapist self to anchor me, but this dialogue requires courage to be intimate and honest. I wonder if I am capable.

We sit in his basement with a scratchy blanket on our knees, as I anxiously wonder if my new tape recorder will work. At the same time I wonder how my husband is, as I left him making polite conversation with my uncle's wife upstairs. Are they wondering what we are discussing downstairs?

He says slowly, "No, racism was not the main reason I left." My long-held assumption momentarily floats away. What does this mean now? He tells me he came to Canada to begin again: a new life, a new job. He does not want to be perceived as someone who cowardly ran away. Did my questions about his leaving further diminish him? It seems to me that he needs me to clearly understand his reasons for leaving. I feel a need to honour this, while still I wrestle with what this means for me and for him. Self-doubts creep in… Were my assumptions off base? Was I too committed to these assumptions before hearing his version of events?

Acts of reinvention

It is as if racism had blighted his life for many years; the hurt and the vividness of the memories live on and become ignited as he speaks of it after 40 years. He says he felt like a victim, which left him terribly alone and split him apart. He says, "I don't know if white people could relate, or appreciate the racist experience. You have to be on the receiving end of it. Only our people could understand this shared experience, to know what it is like to be spat at, to be hated. I do not know if they would be able to really make a connection. You have to live through something like that."

He became vigilant and wary of whiteness. It has been 30 years since he experienced such overt racism, yet he still sees all white people as outsiders. I can psychologically understand this but emotionally it does not fit for me. I cannot feel this way because our narrative experiences are different.

His own racism remains unacknowledged. He does not see it as racism, but rather as a wish to preserve the integrity of his culture, with the lines drawn in a colour-coded way. Whiteness must be kept out or at best treated with a large dose of scepticism. I try to wonder with him whether his racism precedes or emerges from his own racist trauma. How does whiteness threaten his cultural and religious beliefs? I try to get into a dialogue about this, but he is rigid and fixed in his ideas just like those who hated him for what his skin represented.

It seems these feelings became more pronounced when he began to reinvent himself. This reinvention of himself, he believes, was born from the isolation and emasculation of the racism that penetrated him. He needed to recreate and recapture a self by finding value in his culture after coming from such a place of shame. He found a resilience and strength that came from his community and culture, mainly from his spiritual connection to music. He made these connections to preserve a self that had been discounted. “He felt embraced and accepted in this place… a place to stand with his hurts.”

The more toxic effects of the shame and indignity went away, yet he remains mistrustful of anyone who tries to get too close. This mistrust includes me and I realise there is an awkwardness that sits between my uncle and me that does not go away.

I felt deeply hurt and angry by the racism he described, but more so that he had nowhere to take his woundedness. I begin to wonder if I in some way represented the England he had to leave behind. How do I speak of my anger at being left and feeling forgotten? I try to talk about this but the words do not come out right and they stick in my throat.

He reads the narrative that I have taken from him and insists he has nothing to add or

change. "It's an accurate description and it's interesting to know of you through doing this," he says. He sees my expression of sadness at his leaving England as his failure; I cannot quite find the words to explain how much he meant to me that made his leaving so agonizing for me. Is it too late? It is as if he has already turned away. His world seems to exist of outsiders and insiders. I think I begin to exist somewhere in between for him, as the residual effects of this trauma mean that he remains far away.

As we are preparing to leave, he shows me photographs he took of me as a child from an album as closed as his past. He tells me that his happiest memory of those times was the crinkly smile that I saved for him as a child. Despite this, I feel heartbroken all over again.

Healing some wounds

As I listened to and then transcribed my uncle's story, he maintained power over his words as he revised and amended his descriptions. I wrote the narrative piece that he had editorial control over. He was able to acknowledge his loss of self due to racist trauma, but the recognition of his resilience and his sense of agency was made real by the act of linking events to his act of self-expression. I noted that his resilience was activated to survive adversity. He expressed this resilience in the form of forgiveness: "I have survived so much and learned that forgiving others (racists) has helped me have another chance at life."

I grappled with the need to see my uncle as a survivor and hero, and preserve my continued idealisation of him. I can see how he continues to bear terrible scars that I naively believed could be bridged by this research. Yet, what was healing was making sense of these previously unspoken trauma experiences that we were no longer compelled to exclude, a behaviour that was normalised within the family. These narratives brought validation and the possibility of new attachments. However, this narrative was not entirely healing with orderly resolutions.²

My uncle's residence abroad meant the dialogue we were able to share in person was concentrated over a week and followed up by telephone and email contact. I felt disappointed that I did not have more time with my uncle in the research, but is this not how I began, lamenting the loss of my time with him? He seemed unengaged after a time and denied wishing to change the material in the text after the first few revisions. He said there were no negative effects of the research on him, but I wondered if he felt discomfort at our increased contact. I have now not heard from him for a number of months and suspect he wishes to re-establish some distance and renewed separateness. I have honoured this for now and so I continue to feel his absence every day.

In writing about racism and trauma, I am writing about my life, family, and community, which is quite charged. I have become careful not to contribute to the splitting in the world of racism, or in believing that the racist monster prevails and that those of colour are helpless and victimised. I have found that by opening up categories and sitting in between these splits and divides that I can see the situation more clearly. I cannot simply hate the racist, because I have loved those who have voiced racisms of their own, like my father and my uncle. Similarly, I have been touched by this work, wrestled with forgiveness and humanness, and appreciated that the resulting embodied awareness may go a long way in creating connections across divisions.

Coming home again

A gang of boys corners me and threats me, but they become half-hearted and change their minds because they are unsure of where to locate my colour or ethnicity. I feel initially relieved and then angry that they do not recognise me for what I am. I try to call them back. (Saira, eight years old)

I go to Mexico, Mexicans claim me; in Italy they speak to me in Italian that I grope to understand; in Paris, the police stop me and assume I am an Arab; and in India, they do not know where I am from. A client comments to me about how much she despises Pakistanis and how relieved she is that she can speak openly of her contempt, as it becomes clear that she thinks I am from Jordan. (Saira as an adult)

My family would joke and say, "You may as well be white." This was not just a form of shadism, but to emphasize my difference from them. My skin colour is not easily identifiable, yet I am kept othered and my difference is imagined. All of this points to the idea that skin colour is unimportant in itself, but the projections, internalisations and consequences it carries do matter. We cannot ignore or minimise this impact as sometimes it becomes a matter of life and death, be it physical or psychological.

I internalized the shame of my cultural difference, and my Asianness seemed inexplicably both a bad and a good thing. I have struggled with the shame that glued my insides together and writing this has been a battle of sticking and unsticking those glued parts. This work gave shame a place to speak from. I have wrestled with finding my voice and I recognise that the humiliation and guilt at being a witness to racist trauma has been like an eighteenth-century corset encasing me and defining my shape. I have reframed this narrative as one of transgenerational and intergenerational racist trauma. I intimately feel the terrible loss and abandonment by these significant males. Now I am less bound up and defined by this trauma. I am not sure, though, where I go from here.

The effects of these traumatic absences have left emptiness in my life, and acknowledging the pain and sadness of missing these men who were once vitally present has changed something between us. I am able to love them just as they are in the hope that there will be moments when they will be returned to me, which happens every now and then with a smile a word, a gesture, or a memory.

I am changed in other ways, as well. This is best illustrated with an ordinary encounter of getting into the same taxi with four years in between.

Sometime during the beginning of my research, I slide into the taxi as I register the racist hate in the taxi driver's eyes; he glares at me. I am surprised and uncomfortable as I inhabit his confined territory, his taxi seems like a closed-off, taut world of hate and revulsion that leaves me unsettled and unsafe but reminds me that this work means I have to be able to dwell in this place. (Saira)

Four years later, my research is in the final revision process, and another taxi ride…

After spending an afternoon revising my research, I am cooking rice with my mother… the aromatic Indian herbs and spices envelop me… nice to be home again. I feel a mixture of self-consciousness and pride about my project. I get into the waiting taxi preoccupied with these very thoughts. I look up and slowly recognise it is the same taxi driver. He recoils from me, as if I am able to pollute and invade his being. I look at him steadily, filled with curiousity. Where does this contempt come from? What does it do to him? I experience what I can only describe as warmth, expansiveness and loving compassion for him. I happily beam at him because he is representative of the journey that has reshaped me. I do not experience his hate as a terrible wound. I feel no fear. I am not shamed. In that moment and for a long while afterwards, I feel completely free. (Saira)

The implications of autoethnography for psychotherapy

I think about autoethnography interacting with psychotherapy not necessarily as an approach in itself or a distinct form of therapy, but as a set of attitudes towards self and other which can facilitate the creation of an internal bridging and connection. This means that rather than having a set of explicit tools to work with racist trauma, therapists are required to develop and seek out heightened processes of awareness and embodied ways of being. This awareness migrates into practice in a more accessible and less defensive way by helping the therapist engage in highly sensitive and profoundly painful areas of the client's story through varied subjectivities and reframing processes.

The interaction between autoethnography and psychotherapy is also a journey of personal discovery and a self-reflective process. This work became a therapeutically available surface that I could work on inside and outside my own therapy, transforming the relationships with those in research that I love.

For myself as a therapist, “this journey has enhanced my capacity to be more accessible and present in my client work”. I also feel more able to generate conversations and dialogue about racist trauma and the racial experiences of my clients in the therapeutic relationship. Through disentangling racism within myself and others, I find there is an encouragement of an alternative state of awareness that is more self-reflective, and less guilt-ridden and avoidant. This process produced a deepening of understanding and processing of self-generated and self-defined identities that was empowering as it undermined racist and racial stereotypes and helped me to encourage my clients to do so. I think I am better able to seek out such disconnections and attempt to create a worked for connectivity where I can be less constrained in my language and thinking, having developed the capacity to be more available to enter into the webs of racialised discourse in my clinical work and in myself.

Autoethnography can be a profoundly useful way of accessing memories of complex racially traumatic experiences that may be implicit and built upon sediments and layers of racial slights and injuries that contribute to psychological grief and social maladjustment. Skin colour plays an important part in structuring of the world, and the colour coding of the self and psyche. As therapists, we are called to work through this for ourselves and our clients; otherwise it will reappear as the therapist's unexamined countertransference and will perplex and confound the therapy.³ The engagement with otherness takes us out of what is seemingly familiar and encourages us to travel to alternative places within ourselves. It is from this position that I wish to dissolve detachment, isolation and marginalisation to create connections and healing.

Refuse to wither and die

These stories have found a home inside of me, and I realised that I have been writing this story for the whole of my life. Now that it is committed to paper, I can see how it has helped me to love.

Notes

2 Franks, A. At the Will of the Body: Reflections on Illness (Boston, Houghton Mifflin, 1991).

3 Dalal, F. Transcultural perspectives on psychodynamic therapy; Addressing external and internal realities in The Journal of Group Analysis, 30 (London, Sage publications 1997) p. 203.

4 Bronson, P. Why do I love these people: The families we come from and the families we form (London Harvill Secker, 2005).

For further information on authoethnography:

Ellis, C. The ethnographic 1, a methodological novel about autoethnography ( NY, Altamira, 2004).

Gottschalk, S., Banks, A. and Banks, S.T. Fiction and Social Science, By Ice or Fire, (Walnut Creek, Altamira, 1998).

Don Clark on Psychotherapy with Gay Clients

Posted on by rezendevknowfully.com
Ruth Wetherford: Don, thank you for letting me interview you today for Psychotherapy.net. I’m so pleased.
Don Clark: Well, I am delighted to be your interviewee.
RW: Thank you. Let's start with a brief introduction for those who don't know you, or who have not read Loving Someone Gay, You say on your website that this book is so associated with you it's practically part of your name.
DC: Yes.
RW: What would be a general outline that would orient people to your work?
DC: That would be the book Someone Gay: Memoirs that I wrote, which is about 350 pages long. But I assume what you want is a thumbnail sketch of what my life as a therapist has been like?
RW: Yes, but first give us an introduction from before you became a therapist. You describe in Memoirs being born in 1930, during the Great Depression, which influenced you strongly, because though you grew up in New Jersey in relative poverty, you still had opportunities that gave you your strong desire for education and your love of learning, which has guided you all your life.
DC: It wasn't relative poverty. It was poverty. As in, we moved frequently because we couldn't pay the rent. And my parents really were basically illiterate. My father could not read or write. My mother was able to do some reading and she was the writer. My father's writing was limited to signing his name to things, which he did very meticulously. But there were fortuitous events. Perhaps everyone has them, I don't know. Like when I was in the eighth grade, I hated school, because of course being socially at the bottom of the totem pole you get picked on by other kids. Recess was a nightmare.

But in the eighth grade, bless her heart, my teacher must have seen something, and pulled me from the back row up to the front row of the class, and started smiling at me. And I don't remember a teacher ever having done that before. So I started paying attention to her. And her passion seemed to be diagramming sentences in English. Instantly I became the best diagrammer of sentences in the class. Since that had to do with words, which I had been playing with all by myself unbeknownst to other people-trying to decipher Shakespeare, for instance, which I had decided was a secret code like the ones being used by the Allies and the Nazis. I was already enamored with words, and I had already tried writing poetry, but all of this was unknown to any teacher. So we were in this together, now, the teacher and I. We were doing words. And I became her darling and she became my darling, and when it came time to do the eighth-grade yearbook, she appointed me chairman of the committee. I ended up writing the whole yearbook, and I did it in poetry!
RW: That illustrates the power that an individual can have in a child’s life.
DC: Oh, god, teachers, absolutely.
That one teacher in eighth grade saved my life, I'm sure. I would have been working in a factory like my siblings.
That one teacher in eighth grade saved my life, I'm sure. I would have been working in a factory like my siblings.
RW: How did you come into psychology?
DC: Well, I always had to work, of course. Money was always needed in the family. And so one of the jobs I took when I was in high school was an usher in the fanciest movie theater in town. In the beginning I was only allowed to work days, but when I became sixteen I was able to work evenings. And I remember one of the first evening programs I saw was Spellbound with Gregory Peck and Ingrid Bergman. Of course, I fell in love with both of them immediately. I fell in love with a lot of movie stars during that period, male and female. And the males were silent; the females I could talk about. And I wanted to be just like her. She was a psychologist, interestingly. She was acting as a psychoanalyst in the film, but she was called a psychologist. So, duly noted, I thought I would be a psychologist, so that I can save young handsome men like Gregory Peck who have had these awful things happen to them that they can't remember, but I'll help them remember and they will be cured.

So when I got to college, at Antioch in Yellow Springs, Ohio, I started out as a business major, then I became an art major. Then, I took a couple of hospital jobs in the Antioch work-study program. The first one was hideous. The second one was wonderful, at Chestnut Lodge, which was the mental hospital in Maryland that Harry Stack Sullivan had been the control analyst in when he did his writing, and he was followed by Frieda Fromm-Reichmann, who was still there at the time. I had a chance encounter with one patient who had been mute for years. I was nineteen or twenty years old at the time. For whatever reasons, I think she fell in love with me, and I was able to get her to talk and to move and to ambulate, to the point where I was able to take her on a train trip to visit her mother in New York City, which everyone considered to be a total miracle. Frieda Fromm-Reichmann offered me an analysis at fifteen dollars an hour, which of course I could ill afford, but I understood it was a bargain, if I would stay and work with this patient, which I was delighted to do. By the way, Morrie Schwartz–the sociologist at Harvard, who became known for Tuesdays with Morrie– got fascinated by it and he recorded a meeting with me every week a about this. Everybody was trying to figure out why it was working, how this was happening. Now I know why it was working, but then I didn't.
RW: Why do you think it was working?
DC: I really cared about what she had to say, and I cared about her. She had not had that before. Even in her analysis there, her presumed analysis, which was a joke since she was totally mute, no one was giving her any warmth. So the first time we met was when she raised herself up off the floor and threw herself at me, literally, and I caught her in mid-air. Her legs were wrapped around my waist, her arms were wrapped around my neck, she was grunting and salivating, and she was kind of a mess. But I said, like a well-trained twenty-year-old on the staff, I said, “Mary, I think you’re trying to tell me something.”
RW: But you did it with kindness.
DC: I cared about her, and I came back at night on my own time when I was off duty to sit with her and draw little boxes and ask her questions and say, “If the answer to this is yes, just put a mark here. If it’s no, put a mark there.” I’m laughing and almost on the verge of tears, because it sort of reminds me of Ann Sullivan with Helen Keller. No one had taken the trouble to do this with her. And I wouldn’t have either, had it not been that she had thrown herself at me.
RW: Right.
DC: I guess that makes me a sucker for people who throw themselves at me.

The Importance of Empathy

RW: You’re talking about the role of empathy.
DC: Yes.
RW: As a key ingredient in what makes psychotherapy work.
DC: Empathy and warmth. Showing that you really care.
RW: Showing it. And feeling it.
DC: Yes.
RW: How long have you been a psychologist? Half a century? When would you say empathy emerged as something that psychologists talk about as a key ingredient?
DC: God, I don’t know. I mean, in a way, in the writings of Harry Stack Sullivan you see some of it because, as far as I know, he was the first person saying, “Look, there are two people in the room. And it’s not just this cold analytic idea about the patient, and you sit behind the patient with a pad and paper and write things down. There are two of you there. There’s an interaction going on between the two of you. Pay attention to it. Pay attention to what you’re feeling, pay attention to what the patient is feeling, and to what the interaction is between you. Be real.”
RW: Right, like Carl Rogers.
DC: Yes! Carl Rogers, absolutely.
RW: Who else has influenced your work?
DC: Well, in terms of the analytic school, that was it,Stack Sullivan, Frieda Fromm-Reichmann. Gosh, Carl Rogers played a big part. I was already very interested in what he was doing while I was an undergraduate student. I remember going to the library, I think he had one book published so far, and everybody was making fun of him…
RW: Do you want to say anything about your mixed feelings about Fritz Perls?
DC: Oh, I spent some time at Esalen in its heyday in the early '70s, when I was on a Carnegie grant mission studying the new human potential movement. I really paid attention to what the Esalen staff were doing. I was permitted into the royal presence of Fritz Perls, who was the reigning diva there at the time. And of all the people I studied on my Carnegie sabbatical from university teaching, he put more fear into me about what was being done with all these new things than anybody else. I named in my report Marion Saltman, who was a woman who did play therapy with adults on a houseboat in Sausalito, as the person guaranteed to do no harm, and often did a lot of good. I named Fritz Perls as the person who was most likely to do harm while sometimes doing a lot of good. He was very good at what he did and very smug.
He was like a surgeon who went into the operating room, did everything exactly right, laid the guts out on the table, and then smiled at the young residents and said, "Okay, you take over now," and pulled off his scrubs and left.
He was like a surgeon who went into the operating room, did everything exactly right, laid the guts out on the table, and then smiled at the young residents and said, "Okay, you take over now," and pulled off his scrubs and left. And I witnessed one, and know about another one, where following his dramatic interventions, the people went into psychotic episodes. Now, I'm sure he rationalized that as saying, "Well, that was what they needed to do." One of them was the wife of a colleague in the university where I taught. I don't think that's what she needed to do. And it brought a lot of grief into that family for both of them. So, I have mixed feelings about his diva behavior.
RW: Well, it sounds like it wasn’t compatible with the importance of empathy.
DC: Right.

Early Struggles for Gay Rights

RW: Going back to the work you're best known for, Loving Someone Gay, you talk a lot about the importance for gays of being visible and resisting discrimination in any interaction that you have energy to deal with. If you hear a slur, if there's legislation, if there's something in writing, etc. I believe this is important for a gay person to become able to do. This is something you did in your efforts toward depathologizing homosexuality within professional psychology. What were some of your activities toward that?
DC: Oh, boy. Well, the roots of this are back at Antioch when I was an undergraduate there, because it was, and apparently is going to be again, a very social activist school. I think within the first weeks that I was there as a naive eighteen-year-old freshman from New Jersey, we were picketing the barbershop in downtown Yellow Springs, Ohio, population 2,000, because the one barber in town would not cut black people's hair, saying he did not know how, because they have different hair. Well, that was just a small example. Actively advocating for disempowered people permeated the school, and during the time that I was there, people took it really, really seriously. So, going back to Mary, the woman at Chestnut Lodge, perhaps I wouldn't have been smart enough to do what I did.
RW: If you hadn’t had the Antioch experience.
DC: If I had not already been immersed in that very well.
RW: So you were primed for this struggle. Because Stonewall* was in the summer of ’69.
DC: June '69. But I was already rolling before that.

Coming Out as a Gay Psychologist

RW: Yes. So how did you address professional psychology about this?
DC: Oh, god. I think I started writing letters to the editor. I know I wrote a letter to the editor of Time magazine, when they did a big expose about gay people, and my father-in-law at the time was devoted to Time magazine. And I was beginning to get it, that if I said, "Hey, I'm the expert in this field because I am gay," that's where I was going, that's what was beginning to happen, other therapists backed off. They had no credentials. But Time magazine, lo and behold they printed my letter as the lead letter two issues later. My father-in-law called my wife and said, "Hey, Don's letter is the lead letter in Time magazine this week. I don't know what he's talking about, but isn't that great?" And I wrote letters to the APA (American Psychological Association) too. I was beginning to get in touch with other gay therapists, mostly not out yet, but it was happening. The groundswell was beginning to happen, when I moved back to California, in January, 1971.
RW: Being gay was still officially a mental illness.
DC: Oh, absolutely. Absolutely. And I could lose my license. I had a license in California, one in New York, and I could lose them in both places for “moral turpitude.”
RW: If you were homosexual…
DC: Guaranteed, if you’re homosexual, because the law describes homosexuality as criminal, the church describes it as sinful, and psychology describes it as a mental illness, you’re going to be tossed out because it’s moral turpitude.
RW: Well, when I was taking abnormal psychology in graduate school in 1971, it was still in the DSM-II as a mental illness, right between alcoholism and personality disorder. How did it get taken out of the DSM, and what was your role in that?
DC: I think the first public appearance about it, per se, was here in San Francisco at a Western States Psychology conference, and I was the new kid in town, but the word got around fast, I had come out, and I had left the university and come to San Francisco specifically because I had decided to start a full-time private practice devoted to gay people.
RW: Were you the first in San Francisco?
DC: Absolutely. Or anywhere.
I was the first one to say, "I'm gay. I'm devoting my practice to helping gay people, their families, and their friends in any way I can."
I was the first one to say, "I'm gay. I'm devoting my practice to helping gay people, their families, and their friends in any way I can."
RW: You were full of moral turpitude.
DC: I certainly was. So at the Western States meeting, there were four of us presenting on a panel on homosexuality, organized by John Neumeyer. I think all of us were gay, but I was the only one that was going to say it. I didn’t know I was going to say it actually, until I got up, and as I stood in front of the microphone, before I had said anything, I looked at the audience, and what I saw was a big room, packed with about 250 people who were very interested in what homosexual people might be like.
RW: Wow, big room.
DC: Well attended. Very well attended. I stood there, I looked, and I just opened my mouth and said what I was thinking and feeling, which is, "You know, as I look out at you people, I'm sorry to tell you, I think I see the same smug faces that I've gotten used to seeing at psychological meetings. People who either think they know all about homosexuality and have decided that it really is sick, or people who are in some way or another just beyond this. You don't even have to think about it. You can just come and be amused. Well, okay. Here's what I want you to do, for your amusement and mine. I would like every man in the audience to reach out with his right hand and put it in the crotch of the man seated nearest you."

At which point there was a standing ovation, and I think John Neumeyer nudged over close to me and said, "There are no laps out there now." But that did a lot for me. I realized if I could stand up there and call them out on their prejudice and their smugness, all I had to do was talk about what I was thinking and feeling, and people were going to listen. And they did. So from there on, I kept using my slightly false pretense in saying, "Hey, I'm the expert on this. I know about it. I'm gay." And what are you going to say to that? If a black person says, "Hey, I know about being black. I'm black," and you're white, what are you going to say?
RW: Was there any backlash against you?
DC: Yes. But I didn’t care and it truly didn’t matter. Everybody said, the friends that I interned with out here, said, “Oh my god, you’re committing professional suicide. Never mind losing your license, you’re never going to be able to have a full-time private practice. You’re going to be persona non grata.” Au contraire. I had started a little practice in Menlo Park and one here in the city, seeing which would work better. Both of them were filled immediately.
RW: Beautiful.
DC: No problem getting customers. Both of them were filled, and filled with gay people who wanted to talk to someone who would understand what they were talking about.
RW: And who would not think it was a diagnosable mental illness.
DC: Absolutely.
RW: How did it stop being that?
DC: Well, you see, as soon as a few psychologists started to be visible and probably gay, and then visible and gay, and then some more thought it might be safe to put a toe out of the closet… as soon as we started to be visible, gay psychologists’ organizations formed. All the liberation movements were happening at one time. And the time was right. People could smell it. It was going to be okay.
RW: The paradigm was changing.
DC: Yes. During that time, I joined a committee that was working with the San Francisco mental health association, or the county mental health association I think, working on this problem, trying to figure out if homosexuality might possibly be considered not a mental illness. It was amazing. From this committee, Sally Gearhart, Rick Stokes and I became the feared trio on the speaking circuit, because Sally knew the bible inside out and she would come wearing a dress or a suit and stockings and high heels. Rick was a lawyer, knew the law inside out, and he had been hospitalized for this mental illness by his parents as a youngster, and I think given shock treatment, as I recall. I was the psychologist, I was out. So all three of us were out: law, religion, psychology.
RW: It must have been around that time that the APA made the change.
DC: You know, it was actually the American Psychiatric Association.
RW: They were first.
DC: Well, because they move faster. They were just working on it at the same time. And there was actually only a thirteen-month difference between the two associations. But it looks like there’s a longer time-span because the American Psychiatric Association did it in December of 1973, and then not a month later but the following January of 1975, the American Psychological Association did it. The American Psychological Association’s change was much, much more comprehensive. The ones that lagged far behind, of course, no surprise to anybody, were the psychoanalytic people who didn’t come out for another five years, I think. But wanted to make sure they wouldn’t get shot. So then the book.
RW: Then the book. This all led up to Loving Someone Gay.
DC: I wrote it in ’75. At first, nobody would touch it with a ten-foot pole.
I got a scolding letter from the Editor in Chief of Basic Books, saying, “Doesn’t this man, he calls himself a psychologist, and doesn’t he understand these people are sick and they need help? And this is not going to help them, it’s going to help them deny their sickness.”
I got a scolding letter from the Editor in Chief of Basic Books, saying, “Doesn’t this man, he calls himself a psychologist, and doesn’t he understand these people are sick and they need help? And this is not going to help them, it’s going to help them deny their sickness.” Finally, after a year of many refusals, when Celestial Arts agreed to publish it, they sold out the initial five thousand copies before the publication date, which was January of ’77. We were really happy. But soon it collided with Anita Bryant**, so I was suddenly wanted on television and radio all over the country. Being basically an introvert, I hated the idea. But I knew… where would this kind of publicity ever come from again? So I did that. I spent about a year doing that.
RW: How many copies did the book sell?
DC: Beyond count, I mean, truly there were many printings, many different editions, in many languages. It was in two different kinds of paperbacks, mass-market editions, which was where the count got lost because nobody could figure out how many copies Bantam or New American Libraries sold. But that was why I was getting fan mail from people all over the country. Also hate mail. The ones that moved me the most were exactly, exactly the ones I wanted-the kids who had been able to sneak into a little drugstore in Podunk nowhere and get a paperback copy of this. And they suddenly knew there was another gay person somewhere out there in the world, saying, “It’s okay, it’s okay.” Now I get emails from all over the world.

Doing Psychotherapy with Gay Clients

RW: So, Don, turning now to the issue of therapy with gays, what are some of your thoughts about how psychotherapy with gay people, men and women, is different from and similar to therapy with straights?
DC: Well, we have to get into the psychodynamics of what does it mean to be gay. And, not in the interest of selling more copies of Loving Someone Gay, I really would encourage those who are interested to pick up the 5th Edition, the new one, and read it, because I can only give a few words here. The main special dynamic for a therapist to understand is that a gay person goes through a different maturational process than a straight person does. We actually go through two at the same time. We get matured through the steps as if we were straight people, and also as gay people.

The different dynamics in development of the gay childhood, young person, adolescent, and so on, is that even today, let there be no mistake, most gay people are growing up invisible. They are having to learn how to become adult as straight people do. They're also having to learn at the same time what to do with being invisible, with having nobody know who they really are, with being terrified of what would happen if they were known. Black people grow up in black families, usually. Jewish people grow up in Jewish families. Gay people do not grow up in gay families. The vast majority of the time, they do not have any support around who they are.
There is nothing comparable in the human experience. It is as if the gay child is the result of having an egg from outer space planted in the uterus of the mother
There is nothing comparable in the human experience. It is as if the gay child is the result of having an egg from outer space planted in the uterus of the mother, and then appears looking just like the people who live on this planet, and grows up, develops, but all that time something different is happening inside this person; and he or she understands early not to let it show, or not to let it show enough that he or she will get into trouble because of it. And trouble, is indeed, what awaits most of them. So, you live two lives. You hide the life of your true self.
RW: As an alien.
DC: An alien, who has these strange and different feelings about other people of the same gender, which you dare not reveal; and you learn to live as if you were having all the same feelings that your parents, and the preachers, and the teachers, and the police, etc., are having.
RW: So you’re saying that when a person discovers that they are defined by the majority as being in some way deficient or sinful or ill or illegal, that that creates a secret part of themselves, that they can’t gain approval of, and so they have to hide that. And that split between what they hold inside and what they express is part of the development that therapists must understand.
DC: And that the therapist needs to go back with them and visit through every level, every age level, every stage of that development. How has it affected them as they grew up? If they knew when they were five years old, what was like that? If they still knew when they were fifteen and were maybe even experimenting with having sex and nobody knew, what was that doing to them? How did they feel? What did that tell them about themselves? Because it affects people differently.
RW: You don’t want therapists to stereotype gays.
DC: And you always have to be on their side. It doesn’t matter how it looks to you. It matters how it looks to them. The biggest mistake is for therapists to think or say: “I’ve been studying this for years, I know what you’re thinking. I know what you’re feeling.” No, you don’t.
RW: What do you see as some of the implications of this for therapists?
DC: Well, there are a few things I put into Loving Someone Gay, aimed at everybody who wants to help gay people:
  • Number one: The gay person probably has learned to feel different. Keep that in mind.
  • Two: A gay person may have learned to distrust her or his feelings. Very important for a therapist.
  • Three: A gay person may have a higher degree of self-consciousness.
  • Four: A gay person may have decreased awareness of feelings, such as anger generated in response to a punitive environment.
  • Five: A gay person, often invisible, as such to others, is assaulted frequently with attacks on character and ability.
  • Six: A gay person is more likely to fall victim to depression.
  • Seven: A gay person may be tempted to dull the pain that surfaces, by making use and misuse of alcohol and other drugs.
  • Eight: A gay person who is respected and loved, but who is hiding his or her true gay identity and facing what she or he believes would be a ruined life, if the truth were to be discovered, is at a high risk for a fatal accident, or a seemingly inexplicable suicide.
  • And, nine: A gay person usually has lived in two worlds simultaneously.
This is why
I believe it usually is much better for gays to see a gay therapist than a straight therapist, and the therapist must never, ever hold back on revealing that they're gay.
I believe it usually is much better for gays to see a gay therapist than a straight therapist, and the therapist must never, ever hold back on revealing that they're gay. Otherwise they're acting like they're ashamed of it. They have to be able to be supportive, and the first thing that I tell young trainees is you always say something positive and affirmative when the person says anything about sexual desires, sexual fantasies, sexual whatever. If it's homosexual, you're there. You're on it, you're with it, you smile, you sit forward in your chair-
RW: Say more about why you believe gays and lesbians are better off seeing a gay or lesbian therapist.
DC: If a gay person walks into your office with a seemingly small or large problem, you may make the mistake or thinking that you can deal with it just as you would for any other person. Well, that's not true. Maybe if they just want advice on whether they should contact a lawyer because they're getting a divorce, yeah, you can deal with that just as you would with a straight person. However, if you're talking about psychodynamic issues, from day one, everything is different. They are very eagerly watching you to see if you might have any idea of what their life is like. And chances are, unless you have been through it yourself, unless you, too, were born gay and had some decent therapy yourself, so that you could explore your own internalized homophobia, which comes with the course for gay people and for not gay people.

We all have internalized homophobia because we live in a homophobic culture, which is not that unusual. Most cultures on this planet are homophobic, which is a term that was created by George Weinberg, who was a statistically oriented psychologist in New York City. He hit on exactly the right word. If you're phobic about snakes or spiders–two familiar phobias that people have–it doesn't necessarily ruin your life, but you certainly don't want to go near them, and anything that hints of them is going to make you a little uncomfortable, to the extent that for many people, with snakes for instance, seeing a picture of a snake in a book makes them consciously and/or unconsciously uncomfortable. It's just, "I'm not sure I want to go there."

Okay, so now you have a homosexually inclined client in your office, and you, as far as you know, have never had any of those feelings yourself. Or maybe you did and well, you took care of it. You're all grown up now. You've had your therapy. What are you going to do? You know, how are you going to let this person know that you really understand what he or she is feeling? My opinion, I don't think you can, unless you've been down that road yourself. And even then, unless you've had some expert help from other people like you, who have been down that road before you, who can help you to see that it really is okay to be you.
Whatever the presenting problem is, you don't go anywhere with your client unless you have that magic thing called rapport.
Whatever the presenting problem is, you don't go anywhere with your client unless you have that magic thing called rapport. And you're not going to have that rapport unless you can illustrate that you have genuine, genuine empathy. And you can't have genuine empathy if you don't know anything about the world this person came from.
RW: Well, you know there is such a big range, from low to high, of empathy or experience with gay people, within a distribution of therapists, as well as a range of how much a therapist has examined his/her own homophobia, so, it is confusing to me for you to say that you feel like gay people should only see gay therapists. Is that what you mean?
DC: Well, if I had my druthers, that would be true. I don’t think it’s possible, of course, because there are not enough gay therapists to see all the gay people who need to be helped. There is another solution. I don’t think we’re anywhere near doing it yet, but if therapists who are not themselves gay, and have not confronted their own internalized homophobia, were willing to become really, really, really familiar with the experience; to immerse themselves in it. A one-day, continuing ed course, or lots of reading about it doesn’t quite do it. It doesn’t give you the feel of what it’s like to be such a person.
RW: That is true. The subjective experiences are much more enriching to one’s understanding.
DC: So, if you’re a therapist who is not gay oriented, not gay yourself, and you want to really familiarize yourself with what it’s like to be in this world, to be one of these people, go where they go. Do what they do. Have lots of them as friends. Have lots of them in your home. Have your children be familiar with them. You know, if you’re not that comfortable, you’re not there.
RW: Well, I agree with that. But doesn’t it seem like there are other things that are very alienating besides just the fact of being gay, and having that be a secret. There are so many things about the self that are denied, cause a lot of shame, and cannot be accepted in different social circles, families, communities, cultures. And that the effective therapist knows that it’s this individual person’s experience of their situation that is important to learn, and to be open to it. And to ask the questions empathically. Isn’t that your point? Do you think it’s possible for a straight therapist to be sensitive to a gay client?
DC: I think it’s possible if you are willing to learn. That when that person sits down in your office, someone is sitting there that you have to assume you don’t understand.
RW: Like what you were saying earlier about Carl Rogers, that got him laughed at.
DC: Yeah.
RW: What advice would you have for straight therapists that you already haven’t mentioned, in working with gay clients?
DC:
Get out into the community. Get to know gay people. Get to appreciate what is better about the life they are living than the one you are living.
Get out into the community. Get to know gay people. Get to appreciate what is better about the life they are living than the one you are living. Be honest. Find out something you’re envious about. If you can’t find envy in another world, you’re not open to that world. So, maybe that’s enough about that. Get out, read about it. You know, meet people, go. Eleanor Roosevelt used to immerse herself in black culture. She didn’t sit home and read a book about it, she got out there and did it.
RW: Don, you quote Horace Mann as having a philosophy that influenced you. What was the quote?
DC: The quote, which is on the one monument that exists on Antioch’s Yellow Springs campus, is Horace Mann famously saying, “Be ashamed to die until you have won some victory for humanity.”
RW: Would you say you have fulfilled that challenge, and what is that victory?
DC: Well, I’ve tried. And I think I have. Probably through the book, since it has reached so many people and obviously done a lot of good, or they wouldn’t be writing me and telling me that. It’s certainly more of a contribution than I ever thought I was capable of making. And I’m still stunned that it happened, that I was blessed with being able to do this.
RW: Yes. Well, thank you so much for spending this time with me.
DC: Any time.

H2O Under the Bridge: A Case of Trichotillomania

Posted on by rezendevknowfully.com

The Concerned Hairdresser

"Dr. A., I'm so glad I caught you," a soft, earnest voice said. "This is Sebastian from Sebastian's Guild Salon in San Francisco."

"Do I know you?" I asked.

"No, we've never met before," Sebastian said, "but I understand you specialize in trichotillomania."

Sebastian's precise and deliberate pronunciation of the difficult word indicated perhaps a more than casual level of familiarity with the disease. "Have you been diagnosed with trichotillomania?" I asked.

"God, no!" he exclaimed, "unless you consider baldness a natural form of trichotillomania…"

"No, baldness is quite different," I said, appreciating the caller's attempt at levity.

Then, injecting a good dose of drama into every superlative, Sebastian added, "Well, if I still had my hair, the very last thing I would do is compulsively pull it out! I simply love and respect hair too much…This is not about me, Doctor, but about my dearest friend—who is also a top client of mine. She has the worst case of trichotillomania you have ever seen. I've worked with her for almost ten years now, but as creative as I am with hair—and I'm pretty good at what I do!—I've finally run out of tricks to cover up her bald spots. They're bigger than ever now, and I have less of her hair to work with, so I am officially giving up and asking for your intervention."

"Why doesn't she come in for a consultation?" I asked.

"She won't come in alone," Sebastian answered. "She needs me for moral support, she says, even though she might change her mind if she spoke to you. You seem very nice and, umm, quite friendly for a shrink. Forgive my prejudice, Doctor, but I've had some awful experiences with your profession in my day. This is not about me, so I won't go into how I was restrained against my will and given medications intramuscularly—intramuscularly!—or how I was court-ordered to get shock therapy—shock therapy! But, thankfully, all that is behind me now. H2O under the bridge…So, going back to my friend Pat, I really do think you would find me quite helpful if I came in with her. I don't know if you know this, but hairdressers are their clients' confidants, and I can give you quite a bit of important information about Pat that she may have forgotten—or that she may not even know about herself!"

Although quite worried about what I was agreeing to, and about the considerable additional baggage Sebastian was sure to add to the mix, I could not create obstacles to Pat's first visit when she seemed to be in such great need of help. "If Pat is OK with your accompanying her, I am OK with it, too," I said. "Let's all meet and go from there."

"Sounds good," Sebastian said. Then, taking on an even more theatrical air, he added, "I do have one last question, Doctor. It's for my own personal peace of mind, really. Do you think I've been enabling Pat's behavior all these years by doing such a good job covering up her bald spots? I'm so very guilt-ridden by that thought! It just breaks my heart to think I may have been part of the problem instead of being part of the solution. To think that, for years, I jokingly called her Loulou, even giving her a parrot for Christmas one year, instead of pushing her into treatment, causes me intractable insomnia. Please, Doctor, tell me that I have not contributed to my best friend's devastating problem…"

Sebastian was referring to Loulou, the world's best example of trichotillomania across species, a parrot from a French novella by Flaubert with "his front blue, and his throat golden," who displayed a "tiresome mania" of compulsively plucking his own feathers. As delivered by Sebastian, however, this obscure literary reference came across as more show-offish than cultured. His penchant for high drama, combined with his feeling of victimization by psychiatry, made for an intriguing but potentially combustible personality mix that left me both very curious and very nervous. Despite reminding myself that I would not be his doctor, I was already concerned about what role Sebastian would play in his best friend's treatment.

"I believe you wanted to help Pat the best way you knew," I said, trying to reassure him. "It's not unusual for patients with trichotillomania to go for many years before seeking professional help, and most of them don't have talented hairdressers helping them out! I doubt that Pat would have come to see me much sooner if you had not been involved all these years, though I cannot say that with complete certainty. I'm glad, however, that you have now decided to help her get psychiatric care. It's absolutely the right thing to do."

Trichotillomania: An Impulse Control Disorder

Although the usual course of trichotillomania has been well described, much is still unknown about its causes and treatments. It is estimated to affect around 1 percent of the population, with women being more at risk, although women may also be more likely to be included in the statistics because of a greater willingness to seek treatment, whether from a psychiatrist or a dermatologist.

Diagnostic Criteria for Trichotillomania:

A. Recurrent pulling out of one's hair, resulting in hair loss.

B. Increased tension immediately before pulling or when trying to resist the urge to pull.

C. Pleasure or relief while pulling and immediately following.

D. The pulling is not better explained by a skin condition or other medical or psychiatric illness.

E. The pulling causes significant distress or disability.

The overwhelming anxiety people feel before the behavior and the relief that comes with the behavior are shared by other impulse control disorders as well, including kleptomania, pathological gambling disorder, and compulsive sexuality (although the last is not formally included in the DSM-IV). In all these conditions, the pathological behavior varies, but a thrilling sensation is present, which distinguishes them from OCD, where the patient rarely derives any pleasure from the compulsion. So, whether it is the hair pulling in trichotillomania, the shoplifting in kleptomania, the betting in pathological gambling, or the repetitive cruising for sex in compulsive sexuality, these behaviors are experienced as pleasurable, although the patient is also guilt-ridden and tortured by them and is usually well aware of their negative consequences and the long-term damage they cause.

The pleasurable aspect of impulse control disorders can make them more difficult to treat than OCD, because patients are being asked to relinquish an action that, although problematic, is also enjoyable on some level. Another consequence is that patients miss these behaviors and the thrill that accompanies them when they cut back, and they may feel restless and irritable as a result. This withdrawal-like state has been likened to the physiological withdrawal from addictive substances like alcohol and is, in part, why impulse control disorders have also been referred to as behavioral addictions. In fact, Laurie, a forty-year-old nurse I treat for trichotillomania, describes the struggle to resist her pulling urges as "getting the shakes" and compares this state to what her husband, a recovering alcoholic, felt when he abruptly stopped drinking.

Another feature that distinguishes impulse control disorders from OCD is that the behaviors seen in impulse control disorders are often acted out without awareness, almost unconsciously. Laurie, for instance, would often tell me, "I didn't catch myself pulling until it was too late," or, "By the time I realized I was doing it, I had a bald spot already." Similarly, patients with impulse control disorders like kleptomania, pathological gambling disorder, or compulsive sexuality can feel so disconnected from reality and so out of touch with the risks they are running that they can momentarily justify the stealing, betting, or promiscuous behavior, minimizing what is at stake. In contrast, patients with OCD are usually very conscious of their behaviors and often keep detailed mental or written lists of the compulsions performed and the time spent performing them.

Yet similarities with OCD do exist, leading some experts to refer to impulse control disorders as obsessive-compulsive spectrum conditions. The spectrum concept has been championed by Dr. Eric Hollander, a psychiatrist and researcher at Mt. Sinai Medical Center in New York, who has detailed important parallels among these disorders. For instance, in both OCD and impulse control disorders, people experience bothersome, intrusive thoughts. In someone with OCD, the intrusive thought may be an irrational contamination fear after shaking hands with a stranger. In someone with trichotillomania, the intrusive thought may focus on how one particular hair feels different in the way it touches the forehead. Further, the intrusive thought in both OCD and impulse control disorders is usually associated with an irresistible behavior the person feels compelled to perform, such as hand-washing in OCD or hair-pulling in trichotillomania. This behavior, whether it involves ten minutes of hand-washing in OCD or pulling out a particular hair that feels different in trichotillomania, is often repetitive, stereotyped, and acted out in rigid patterns.

The First Session

Pat followed just behind. As I reflexively do when I am expecting a patient with trichotillomania, I focused on her hair first. My initial impression was that it looked artificially perfect. The immobile, meticulously arranged fringe in front and the impossibly symmetric outward flips on the sides clearly indicated that Pat was wearing a wig. As she shook my hand, I could feel the sweat and tremor in hers.

"I'm glad Sebastian called to make this appointment," she said. "I know it's overdue."

"I'm glad he did, too," I said. "I understand from my brief phone conversation with Sebastian that you have been suffering from trichotillomania for a long time."

"She has," Sebastian interjected. "Where do you want me to start?"

"Maybe we can have Pat start," I suggested.

"He knows me so well," Pat said, "and it's embarrassing for me to talk about this."

"Trichotillomania is probably more common than you think," I said, "and you're in the right place now to do something about it. We can take a break later if this becomes too much for you, but can you tell me how this problem began and how bad it has been lately?"

A long, heavy silence followed, interrupted by Sebastian's muddled outbursts as he tried to control his urge to speak on behalf of his friend. He distracted himself by rotating his rings and moving his swivel chair in semicircles.

"It would be easier for me to just take my wig off," Pat finally said, turning toward Sebastian as if to invite his help. "What you will see is worth a thousand words."

Before I could object to what seemed like an extreme gesture happening too early in our meeting, Sebastian sprang up and positioned himself behind Pat's chair, the speed and energy of the jump causing his chair to complete a full turn on its axis. Then, deftly working his palms underneath Pat's artificial locks, he squeezed both index fingers between scalp and wig, slightly loosening the wig before dramatically and quickly lifting it. Pat closed her eyes, as if she was too ashamed to face me. My eyes, too, briefly closed. I felt like I was somehow violating Pat without meaning to. Before I could establish any rapport with her, before I could offer any meaningful reassurance, an embarrassing problem that she had steadfastly kept from medical professionals for years was now abruptly revealed before the clinical gaze of a complete stranger. Something about the way it had happened felt violent, and for a sad moment, I wished I could roll back the less than five minutes of our meeting and have another chance at my first interview with Pat. But of course there can only be one first interview, and despite my regrets about the course of events, I had to make an assessment of the problem that was now being presented for my evaluation.

The natural light brown hair that Pat's wig had concealed appeared brittle and uneven. It was pulled up and collected in an anemic bun on the vertex of her head. Three one-inch bald spots on the sides were visible through the thin strands that snaked their way back from her forehead. These spots appeared red, indicating inflammation from repetitive damage to the scalp. In part to cover up the bald spots, in part to cover up the redness from inflammation, brown makeup the color of her hair had been applied to the bald areas, complicating the patchwork of color and texture. "See? That is all the hair I have left to work with," Sebastian said, as he regretfully shook his head, sounding unusually subdued and hardly desensitized to the sight. He then released Pat's bun very gently by pulling out the single needle-thin clip holding it, taking the utmost care not to lose one more precious hair in the process. Pat's natural strands fell down, showing a variety of lengths resulting from recurrent bouts of plucking.

"I have these creams I use," Pat said, opening her eyes to locate in her purse two tubes of steroid-based lotion. "My dermatologist prescribed them for me."

"Do they help?" I asked.

"Not really," Sebastian quickly answered. "And neither do all the hypoallergenic products I've prescribed," he added, stressing the "I." "We have a basket in my salon that my helpers jokingly call 'Pat's basket.' It contains a complete line of fragrance-free, dye-free, and paraben-free pomades, shampoos, and conditioners. Very expensive designer products that only our Pat gets to use."

"And what are parabens?" I asked.

"You haven't heard of parabens?" Sebastian retorted, shocked at my ignorance of a seemingly very important toxin. "It's a poison in the estrogen family," he explained. "It's been shown to cause breast cancer. It's usually found in underarm deodorants, but many commercial hair products also have it."

"I'm not familiar with the research on parabens," I said, "but I'm not surprised that all these measures have not helped Pat. They rarely do in trichotillomania, unfortunately."

"So should I stop using these creams, then?" Pat asked, pointing to the tubes in her hands. "I'm not fond of using steroids on my scalp, anyway. I heard they can cause hair loss. Just what I need!"

"Low-strength steroid creams that you apply to the skin should not cause hair loss," I said, trying to reassure her. "Dermatological interventions like these can help with the inflammation and infection that pulling can cause, but they do not deal with the fundamental cause of the problem. They address the consequences of the pulling but not the pulling itself. That is why a psychiatric approach has a much better chance of success."

"'A psychiatric approach?' I don't like the sound of that!" Pat said, looking at Sebastian as though to enlist his sympathy by reminding him of the scars the "psychiatric approach" seemed to have left him with.

"I do," was Sebastian's quick answer, delivered forcefully as he stroked the wig he had placed on his lap. "We've been in denial about this for much too long, Pat."

"How long, Pat?" I asked. "How long have you had this problem?"

Pat paused a bit as though still pondering the benefits of a psychiatric approach, then answered, "I guess it started when I was fourteen or so. Back then, I would just twirl my hair. Innocent enough, right? But then I somehow discovered the joy of pulling, and I haven't been able to stop since."

"The joy of pulling?" I repeated after her, intrigued by her choice of words.

"Yes, pulling, for me, actually feels good," Pat answered. "It calms my nerves."

"She's even used the word orgasmic once—jokingly, of course—to describe the sensation," Sebastian ventured, lowering his voice and looking away from his friend as he pronounced "orgasmic."

"Sebastian!" Pat yelled, reprimanding him for crossing a boundary she clearly did not want crossed.

"Sorry, sweetheart," Sebastian said, sounding genuinely apologetic as he reached over to squeeze Pat's hand. "We have to be completely honest with the doctor if he is to help us."

"It's an anxiety-relieving behavior, Pat," I explained, "so it doesn't surprise me that you experience it as pleasurable—most people with trichotillomania do. That is one reason trichotillomania can sometimes be challenging to treat. I will be asking you to stop a behavior that, at some level, you find soothing." Then, after a brief pause, I added, "But saying you find the behavior soothing is simplistic, of course. Even though the behavior itself feels good, you obviously don't like the consequences, and you don't like the fact that you have the disease. You wouldn't be here if you did."

"I can absolutely, unequivocally, and without reservations, tell you that I hate the fact that I have bald spots!" echoed Pat, nodding in agreement as she squeezed Sebastian's hand more tightly.

The Pleasures and Perils of Pulling

Although many people with trichotillomania pull hair from their scalps, pulling also commonly targets the eyebrows and eyelashes, as well as facial and pubic hair. In fact, the natural tendency for the disorder is to migrate over time, so that a person who started pulling hair from one site may, for reasons that are unclear but do not include running out of hair in the first site, switch to pulling from another location.

The resulting bald spots cause great embarrassment and guilt for the victim, who will often go to great lengths to hide them. Commonly used cover-up strategies include creative hair styling, wigs, excessive makeup, hats, bandanas, and false eyelashes and eyebrows. The disfigurement can lead to avoidance of social situations, dating, sexual relationships, activities like swimming and other sports, and even exposure to windy places.

Despite the Threat of Surgery

"What happened to your neck?" I asked.

"It's acting up again," she said. "My right arm is so numb and tingly I can't get anything done. It happens every so often, usually when my pulling is out of control."

"What's the association between pulling your hair and numbness and tingling in your arm?" I inquired.

"Well, there's this area at the upper left side of the back of my neck, right about here, that I enjoy pulling from for some reason," Pat explained, slipping her right index finger under the brace to demonstrate the location and grimacing with pain as she did. "The problem is that this part of my neck is not easy to reach with my right hand, which is the hand I use for pulling. Well, imagine spending two to three hours a day, your right arm wrapped behind your neck, and your neck bent forward, as you focus on finding more hairs to pull. Now imagine doing this for years… Talk about repetitive motion injury! I have a bulging disc in my spine as a result, and it's causing pain to radiate down my right arm. The brace is to immobilize my neck so I can avoid surgery."

"And does the brace help with the pain?" I asked.

"Yes, it does, as long as I wear it," Pat answered.

"Does it help in other ways, too?" I asked. "Does it reduce pulling as well by preventing access to your favorite pulling spot?"

"Well, yes," Pat answered, "but that's one reason I take it off when I should be wearing it. When the urge to pull is too strong to ignore, I simply take the brace off."

"Despite the pain?" I asked.

"Despite the pain."

"Despite the threat of neck surgery?"

"Despite the threat of neck surgery. Isn't that crazy?"

Dating Stress

"Well, they certainly get worse around stress," Pat replied, "especially dating stress. I'm an attractive—except for my hair—and successful mortgage broker, forty-two, still single, and with no prospects for intimacy as long as I have this problem. The thought of finding myself in an intimate situation that might expose my problem is enough to send me into a panicked frenzy."

"So the bald spots prevent you from dating because they're too embarrassing, and when you do find the courage to date, the stress around that leads you to pull even more," I recapped.

"Exactly," Pat concurred. "It's a vicious circle, and I'm caught in the center of it! I haven't gone out on more than two dates with the same guy for a very long time. The likelihood of some form of intimacy taking place on the third date if things go well is too scary to contemplate…What if he crosses the four-foot normal social distance and gets into my personal space? What if he approaches me in bright light for a kiss and spots the thick brown foundation covering parts of my scalp? What if he runs his fingers through my hair? What if? What if? What if?"

"That is really tragic, Pat," I said. "The idea that even with men you do like, you have to resist seeing them a third time and feel forced to end things prematurely…"

"Absolutely," Pat said. "I always sabotage things to turn the guy off and avoid seeing him again. Like this last guy Sebastian introduced me to, who turned out exactly as Sebastian had described: a handsome, gentle, successful Realtor—a nice Jewish boy, really. And did I say handsome? Well, it came up on our second date that his sister had OCD and, as kids, she would spend three hours in the shower every day while he waited patiently for his turn, and as a result, he now won't allow any of his clients to buy a house with less than two bathrooms…Well, instead of empathizing with his childhood experience or using it as an invitation to open up about my own personal struggles with rituals, I went on to make fun of his sister's OCD in the most insensitive way imaginable! And I wouldn't shut up! Imagine, half-bald me making fun of his poor sister's showering rituals! Talk about the pot calling the kettle black! Well, needless to say, the third date didn't happen.. . And when Sebastian started asking what went wrong, the best I could come up with was, 'Well why don't you date him if he's so perfect?' I don't have to tell you that I haven't forgiven myself for this fiasco yet…"

"So you were intentionally pretending to be a mean person to turn off a guy you really liked so he would not want to ask you out on a third date," I summarized.

Pat nodded, her eyes welling up. This painful real-life example of the consequences of her illness brought Pat's tragedy home to me. Her tears drew me in. More than at any point in my meetings with her, I was able to get past wig and brace to appreciate the real hurt that lay much deeper than the outside manifestations of her illness, disturbing as those were.

I struggled to show Pat I was caring without losing control over my own reservoir of feelings. My theory has always been that you have to project resilience and empathy, almost simultaneously. Any "breakdown" on my part could be interpreted by Pat as a sign of weakness or inexperience and might lead her to doubt that I possessed the emotional backbone and resolve needed to address her problem.

On the other hand, by closely identifying with Pat and openly and transparently sharing my feelings with her, perhaps to the point of tearing up in her presence, I might be- come more "human" in her eyes, thus enhancing our doctor-patient bond. But is this not what Sebastian and other people close to her attempted to do, without lasting success, and are patients not looking for something different from their doctors? And what about my own mental health? Should I not be protective of that, too? Is there not a limit to how much I can identify with patients' problems before I, too, succumb to depression, negatively affecting my own life and severely impairing my ability to help others? Should I not be more like an oncologist, a cancer specialist who empathically delivers bad news all day but who does not bring these tragedies home and is able to sleep peacefully at night?

My internal debate was interrupted when Pat's growing discomfort with the subject of dating and this sad memory started manifesting itself in pulling urges that she seemed close to acting on right there in my office. I could see her reach under her brace with her right hand to that favorite spot in the left upper back part of her neck. I shook my head in an effort to dissuade her from pulling, a gesture I hoped she would interpret as "Don't do it." I wanted her, instead, to process with me the negative emotions our conversation was bringing up and to discuss other ways to dissipate them.

But before I could say anything, I heard Pat's voice come out, almost pleading.

"Please…just one more," she whispered. Then, withdrawing her hand from underneath the cumbersome brace, Pat reached for a much more conveniently located hair sticking out from the side of her wig. With a deliberate, firm motion, as she held the wig in place with her other hand, Pat pulled one more hair—from her wig. I may be imaging this, but I think I saw Pat's tense facial features immediately relax.

Treatment

It is very common for people with trichotillomania to comment that, by the time they "catch" themselves pulling, it is too late and too much damage has already occurred. Increasing self-awareness aims to bring pulling into consciousness. I usually start by identifying with my patient the situations that are likely to trigger pulling. For example, after tracking my patient Laurie's trichotillomania problem over two weeks using a daily pulling log that I asked her to keep, it became apparent that Laurie's worst pulling occurred while driving. With this information, I could tailor an intervention that targeted this high-risk situation. I asked Laurie to keep a pair of gloves in her car to wear whenever she drove. This seemed to reduce her pulling by taking the tactile pleasure out of it.

Competing responses are more socially acceptable, harmless behaviors the person can substitute for pulling. These are usually objects that provide some tactile stimulation, such as a stress ball the person can squeeze when feeling an urge to pull, a rubber band to pull on, or a makeup brush to stroke.

Motivation enhancement helps people with trichotillomania understand and remember why they want to stop pulling. With the therapist's help, the patient develops a list of reasons for stopping. For Laurie, the list initially included feeling more comfortable in social situations, feeling like she did not have to explain herself to anyone, setting a good example for her children, and finding healthier ways to release anxiety. Laurie posted the list on her bathroom mirror to serve as a daily reminder. I kept a copy, too, updating it as needed based on Laurie's progress in therapy.

Changing the internal monologue involves confronting assumptions about pulling that provide justification for continuing the behavior. For example, instead of "I've done so much damage, what difference does it make if I pull one more hair?" the patient is taught to shift her thinking to "Hair pulling is like self-mutilation, and I deserve better than this." Instead of "I'll only pull one hair and stop," the puller is taught to say, "I've never been able to stop at one hair, so I'm not going to test myself."

As with OCD, anxiety can trigger trichotillomania. Relaxation training can diffuse stress, thereby reducing pulling. Helpful self-relaxation techniques include deep, rhythmic breathing, visualization of a pleasant, soothing scene, and progressive muscle relaxation where the person is taught to tighten and then relax each muscle group in sequence from the toes to the scalp. Patients practice these tools in the therapy session and then apply what they've learned in the outside world to reduce pulling when they feel anxious.

Research studies on medications for treating trichotillomania are limited but do suggest that the SSRIs and clomipramine—all serotonin-based drugs well established for OCD—can be helpful. However, for most people, medications should be combined with therapy, as this is likely to give better results than medications alone.

"Treating trichotillomania can be long and difficult," I warned Pat, "but trichotillomania is treatable, and you shouldn't let the effort and time it might take us to control the symptoms discourage you."

"I've never been in treatment before," Pat said, "and I'm as motivated as I can be to get better."

"You told me you were most likely to pull while sitting at your computer at work," I said. "Here, I want you to take this stress ball. Keep it on your desk at all times and try clenching it in your fist when you feel the urge to pull."

I handed Pat a squeeze ball that a drug company rep had given me. I believe he meant it for my personal use—a way for me to handle stress on the job, so I would subliminally associate the relief I got from squeezing the ball with the product he was marketing. It had Paxil emblazoned all over it in phosphorescent blue. The bright colors caught Pat's eye, and she seemed momentarily amused. She gave the Paxil ball a good squeeze and seemed to approve of its consistency. "I feel better already," she joked. Shortly after that, though, her amused look morphed into circumspection. "But the problem is, most of the time I'm not even conscious of pulling," she worried. "How can I reach for my squeeze ball if I'm not aware that I'm pulling in the first place?"

"Excellent point," I replied. "That is why there is a parallel component to this therapy to make you conscious of the behavior itself. It involves having you collect the hairs you pull every day and put them in individual envelopes with the date and number of hairs written on the outside of each envelope. You then bring the sealed envelopes with you to our weekly meetings, and we use them as an objective way to track your progress." Hearing this, Pat's circumspection changed into utter disbelief. And not without some irritation. "Did I hear that right?" she protested, sounding both incredulous and annoyed. "You're asking me to bring a week's worth of hair stuffed in envelopes to your office every week? Is this a joke? Did I forget to mention that sometimes I lick the hairs I pull? Do you still want me to collect them? I'm sorry, but this is a bit on the disgusting side, and I find it hard to believe that people actually do it! I'm afraid your treatment, Doctor, is too embarrassing for this patient."

"I agree that there is an embarrassing aspect to this, Pat," I said. "But some people do it—and with good results, I might add. One way to look at this is to say that we would be using the embarrassment factor to our therapeutic advantage, almost as a motivator. Here's how it works: the fact that you are saving and counting the hairs will make you more aware of the behavior, and the embarrassment of having to produce these hairs in my office every week will discourage you from pulling."

"I still can't believe this," Pat continued, already sounding a bit more resigned and a bit more accepting of the unconventional treatment recommendation. "Can't I just take a pill? Paxil, for instance? I already have their ball! It really would be a lot cleaner…"

"It would, for sure," I agreed. "But in my experience, behavioral therapy is at least as likely to help with trichotillomania as medications are. Plus, it is free of side effects!"

"Unless you consider embarrassment a side effect, that is," Pat quipped.

"I consider embarrassment in this case to be part of the intervention's mechanism of action." I said. "I look forward to seeing you in a week. Just make sure you seal those envelopes!"

Paperwork

"Pat, our trichotillomania patient, just stopped by," Dawn said. "She says she's sick with a cold—although she sounded perfectly fine to me! Anyway, she said she needed to rest and wouldn't be able to make it for her weekly appointment today. She did drop off some paperwork for you to review, though. She said it was important that I get it to your desk soon."

"Do you know what it's about?" I asked.

"I haven't a clue," Dawn answered, "but it looks very official. Seven nicely sealed envelopes, all dated and numbered, although the numbers don't seem to follow any sequence. Insurance company correspondence would be my best guess."

"I think I know what this is about," I said, feeling a bit guilty at having Dawn unknowingly handle a patient's hair—especially hair that might have been licked! At the same time, I really did not want to go into a detailed explanation of what Pat and I were up to. This was a hairy Pandora's box best left closed for now. "Just save the mail in her chart until her next visit," I said.

"I can sort through them now if you want," Dawn replied. "Her insurance probably just wants more documentation before they'll authorize more visits. You know how I can sweet-talk insurance companies into almost anything…"

"I know your clout with insurance companies, Dawn," I said, "but no, really, this should wait until Pat's next appointment…Have you had your lunch break yet?"

Progress

"The neon writing has rubbed off on my hands," Pat announced at the outset of the session. "I think I need a new squeeze ball!"

"That's a good sign!" I replied. "It means you've been taking full advantage of it. You've been doing the hair-collecting part of the treatment, too; I got your envelopes last week."

"And I have another week's worth for you here," Sebastian added, opening his black leather messenger bag to produce a stack of seven sealed envelopes. He looked numb and somehow mechanical as he handed over the envelopes, with none of the drama I had come to expect from him. Pat looked away. "It was either me coming with Pat today to hand-deliver these to you or Pat mailing them to your office," Sebastian added. "She has a very difficult time bringing the envelopes in, although she is religious about collecting the hairs!"

A quick glance at the numbers written on the envelopes revealed a slow decrease in the hairs pulled, from around 150 some two weeks earlier to about 100 now.

"It looks like you are doing a better job controlling your pulling," I commented.

"I'm more conscious of it," Pat explained, "and that translates into better self-control. Plus, I really don't want to have to bring them here, so when I pull now, it's when the urge is impossible to resist and the squeeze ball fails to make it go away."

"May I interject something here?" Sebastian broke in, looking more animated. "I mean, that is all fine and dandy, but it seems to me like we're missing the point. We're not addressing the root of the problem, if you will excuse the pun. I mean, what is causing this? Why is she pulling in the first place? Why does someone as normal as Pat self-mutilate like this? I can't see how squeezing a ball or collecting saliva-soaked hair can be a long-term solution…A band-aid maybe, but as long as the deeper issues troubling her are not addressed, it seems to me that the problem is likely to come back again."

"Well, what do you think, Pat?" I asked.

"I'm torn," Pat answered. "Part of me says, 'Whatever works, I'll take it,' but another part craves some kind of explanation, some kind of answer."

"I can understand your frustration, Pat," I said, "but—as is the case with so many conditions in psychiatry, and in medicine in general—we are far better at fixing the problem than at telling you exactly why you were the unlucky person who got it. Take diabetes, for example—"

"But this is not diabetes!" Sebastian interrupted, becoming louder and more irritated. "Can't you see? Deep inside, Pat-the-patient hates Pat-the-person, and this is her way of punishing herself. We need your expertise in reversing this, so she can start believing she deserves better. Unless she starts liking herself again, she will never stop this self-mutilation nonsense…When I brought Pat in here, I was hoping you would help us get there. I suppose I could have had her work in my salon, sweeping hairs off the floor and stuffing them in envelopes all day long. I guess that would have fixed the problem, too, but I chose to bring her here instead, hoping for more than that!"

"I could not agree with you more that Pat deserves better than to have to deal with this problem," I said, trying hard to hide my irritation at Sebastian's interference in the treatment Pat and I had agreed on, and which already seemed to be bearing fruit. I felt that a change in treatment approach could sabotage Pat's recovery, now in progress. I also wondered about the role his own history of unsatisfying psychiatric treatment might be playing. "I just do not believe that spending hours in expensive therapy to try to come up with a story that may or may not be true about why Pat pulls her hair will ensure that the behavior goes away," I added.

"And I can't see how stuffing hair in envelopes guarantees anything either," Sebastian snapped back.

Feeling that continued confrontation was unlikely to lead anywhere and hoping to talk with Pat alone at the next visit, I suggested we postpone any decisions regarding the future course of therapy until our next meeting, when we would have more data on Pat's progress. Then, clearly addressing Pat, I said, "My recommendation is for you to continue with the hair-collecting and squeeze-ball tools until I see you back in my office in one week." I then discreetly slipped a brand new phosphorescent stress ball into her bag.

The Absent Patient

"Pat is not exactly an ex-patient, Dawn," I corrected. "Not with a piece of mail arriving from her every day…In a strange and unique way, Pat remains a very active patient."

"In a very strange and unique way," Dawn quipped. Then, after a brief pause, she added, "I just can't understand why she hasn't responded to our calls. It's been almost two months already. Maybe I should stop by Sebastian's salon and check on her. I'm thinking of getting a perm before the baby comes anyway."

"Absolutely not, Dawn!" I interrupted. "Perm or not, you are not to have a conversation with Sebastian about our patient. That would be a breach of confidentiality, and I cannot allow it."

"My, my, are we short and testy!" Dawn exclaimed. "Who's the pregnant one here, Dr. A.?"

Besides the obvious ethical concerns around patient privacy issues, one explanation for my irritability with Dawn was my defensiveness around the mention of Sebastian, who, in a sense, had been right to confront me, although he could have done it more tactfully and without the I-could-have-told-her-to-do-that-myself attitude. Like him, doctors—and perhaps especially psychiatrists— want to understand the why behind the symptom and feel some insecurity admitting their ignorance. After all, as doctors, we are not only called upon to fix a problem; we have to try to explain it, too. Only after a satisfactory explanation can patients avoid the triggers that brought on the symptom in the first place and thus feel confident in their recovery and the permanence of the fix.

This powerful drive to explain mental illness has given rise over the years to some fabulously simplistic and often ultimately wrong hypotheses for mental disorders.

This powerful drive to explain mental illness has given rise over the years to some fabulously simplistic and often ultimately wrong hypotheses for mental disorders—from the "schizophrenogenic mom" whose aloof and diffident nature somehow led her child to start hearing voices as a young adult to, more recently, the conceptualization of major depression as simply a disease of "too little serotonin" that is easily treated with medications that raise the levels of this neurotransmitter in the brain. Doctors should feel less threatened answering "I don't know" to questions that push the boundaries of medical knowledge, and patients should not necessarily interpret this "I don't know" to mean "I can't help you."

But even in the midst of my defensiveness around my inability to produce a satisfying cause-and-effect story to explain Pat's pulling, I could not help but notice that the discreetly written numbers in the upper left corner of Pat's daily envelope continued their steady decrease, from around 150 on the envelope at the bottom of the pile to less than 15 as the two-month anniversary of our last meeting approached.

Then, at exactly two months after our last encounter, Dawn paged me with her phone number followed by 9-1-1. I called her right back. "What's the emergency, Dawn?" I asked.

"Dr. A.! Pat is here!" she answered, out of breath. "She wanted to personally drop off an envelope with me, but I told her I wasn't comfortable playing the intermediary for her anymore, and she would have to give it to you in person this time. Should I schedule an appointment for her, or…

"I suppose I can squeeze her in right now," I interrupted, trying to downplay my excitement at seeing Pat again. "Have her come up," I said. "No! Dawn, wait! Is she alone?"

"Yes, she is. Don't worry!" Dawn reassured me. "I'll send her right up."

Barely two minutes later, Pat and I were sitting face-to-face in my office. She exuded an air of both refined elegance and serious business in her white pantsuit with oversized lapel, decorated with a large sunburst brooch whose shiny silver surface echoed the large metal hoop handles of her white leather purse.

It was a mark of undeniable progress that I was struck by other aspects of Pat's appearance before focusing on her hair. Pat was no longer presenting herself as someone who, because of deformity or extreme self-consciousness, was working hard to go unnoticed. That afternoon in my office, Pat had a physical presence, and a self-assured, attractive one at that! As to her hair, it was not lifeless or perfectly symmetric (as in fake), not overly luscious or flowing (as in exaggerated hair product advertisements), and not uneven, brittle, or combed-over (as in "trich hair"). It was pulled back in a neat-looking bun on the vertex of her head, with no random hairs sticking out from the bun or the sides, and no evidence of redness, bald spots, or makeup on the scalp underneath.

"You look very good, Pat!" I exclaimed. "But where have you been?!"

"I have something to give you," she said, avoiding my query into her extended absence.

"OK, but you did not answer my question," I insisted. "It's been two months!"

Before I could press her further, Pat slowly separated the large silver hoops of her bag, then quickly snapped it open to reveal a familiar-looking envelope.

"Please open it," she requested, handing me the envelope. "I'll explain—or try to explain—afterward."

My hesitation and confusion must have been visible as I assessed the envelope, which carried neither the customary flower series stamp nor the number of hairs on it. Just "Dr. A." in large script.

My hesitation and confusion must have been visible as I assessed the envelope, which carried neither the customary flower series stamp nor the number of hairs on it.

"Just open it," Pat insisted. "That's the last thing I will ask you to do for me."

So I did. I opened the white envelope labeled "Dr. A." and found it completely empty inside.

"I'm down to zero!" Pat said, flashing a big smile.

"That's great news, Pat!" I said, my surprise visible. "I'm proud of you."

"I do feel like I owe you an explanation, though," she said. "After our last meeting, I felt like…"

"You don't really owe me an explanation, Pat," I interrupted. "Feel free to explain yourself if you want, but you don't 'owe me an explanation.' I was just worried about you, and I'm thrilled to see that you are doing so much better now."

"I'm doing better for sure," Pat said. "In fact, I can't stay too long! I'm meeting my date in a half-hour."

"You're starting to date again! That's as good a sign as any that things have drastically improved. Is it the same nice Jewish boy you liked so much, by any chance?" I asked, excited that a promising, prematurely aborted relationship might get another chance. "He seemed to really like you, too, as I recall, but you sabotaged the whole thing out of embarrassment that he might find out."

"Who? God, no!" Pat said, letting out a loud laugh. "Didn't you hear? Well, there's no reason why you should have heard…"

"Didn't I hear what, Pat?" I asked, intrigued.

"Well, it turns out he was…Well, he and Sebastian are, umm, together…" Pat said hesitantly. "As like, dating each other," she added. "In fact, Sebastian perceived you as wanting me to pursue my relationship with Neil—that's the guy's name—which I think made him a little jealous. In retrospect, that explains some of his outright hostility toward you last time we all met. I'm very sorry about that, by the way. You didn't deserve it at all!"

"That's OK," I said. "H2O under the bridge, as Sebastian would say. But I must tell you I'm very confused now. Wasn't Sebastian the one who introduced you to Neil in the first place?"

"He did, he did," Pat conceded, "but I'm now convinced that he was using me to test some hypothesis he had about the guy all along. Frankly, I'm confused, too. I could sense Neil was interested in me, but I also know he's seeing Sebastian now. Maybe he's bisexual or something… Anyway, it doesn't take a psychiatrist to guess that I'm a little mad at Sebastian right now. But it's nothing that he and I won't get over in time."

"Well, this is all very fascinating but also very sad, Pat," I said, wanting to give her an opportunity to process her feelings around what had happened. "I know how close you and Sebastian were, and I hope you can salvage your friendship."

But the non-doctor part of me was also simply curious, in a way that was perhaps inappropriate—more gossipy than clinically relevant to my patient. "Tell me more!" I said. "Do you think the two of them are a good match?"

Fortunately, however, Pat would not indulge me. "Well, I could go on and on analyzing this," she said, "but what purpose would it serve besides prolonging the same pointless drama? The fact is, I've moved on, and it's all H2O under the bridge at this point… Plus, you don't want me to be late for my date, now, do you? Thanks for everything, Dr. A. Really, thank you."

With that, Pat stood up, gave me a hug, and disappeared into the labyrinthine hallway of our clinic, sounding a lot more confident in her step and a lot less anxious.

The Psychiatrist's Lot

But what to do with two months of hairy correspondence? Except for the final empty envelope, which I held tightly in my hands and then pinned to the wall in my office, I pushed the rest of the stack toward the edge of my desk, letting it drop off into the trash can. The thud of the falling pile as it hit the bottom caused a feeling in me that, however tinged by a sense of loss and separation, I can still best describe as satisfaction.

Excerpted (with permission) from Compulsive Acts: A Psychiatrist's Tales of Ritual and Obsession by Elias Aboujaoude, MD. Now available in paperback and on sale. For more information and to order, please visit the publisher's website, UC Press, or read reviews and purchase at Amazon.com.